HomeMy WebLinkAbout888583STATE OF WYOMING
SS.
COUNTY OF LINCOLN
I, CATHERINE A. VEIGEL, being first duly sworn, states as follows:
1. That on July 6, 2002, ORIN CHARLES VEIGEL passed away, a copy of the
Death Certificate is attached.
2. That because of the foregoing, CATHERINE A. VEIGEL has full rights of
survivorship and title to the subject property described in the Quit Claim Deeds attached hereto.
DATED this
My Commission Expires:
888
AFFIDAVIT OF SURVIVORSHIP
day of March, 2003.
BOO61. 5 PR PAGE 4
33
RECEIVED
LINCOLN COUNTY CLERK
a,s `s.? P;, 3 2
0
CATHERINE A. VEIGEL
The foregoing Affidavit was acknowledged before me by Catherine A. Veigel this i
day of March, 2003.
Witness my hand and official seal.
G A,. 117
NOTARY UBLIC
SHERILYN MATTHEWS NOTARY PUBUC
County of State of
Lincoln n;' Wyoming
My Commission Expires _1_23:22h-4
TYPE OR
-PRINT IN
PERMANENT
BLACK INN
:.00-NOT USE
FELT. TIP PEN
.CAUSE OF
WIN
CERTIFIER
If E mtren PAX
NATURAL CAIISES.
E C0 ONE
HOST COMPLETE
f CEmpluiE'
TO BE USED
ktlN EktnI AL
CAUSE§ ONLY
3. CEOENT.— NA
E nnsr
SOCIAL SEOURITY NUMBER;'i
52 42 =0Q83
:WAS DECEDENT EVER 1N U.S..ARMED
FORCES?
❑Yes 1?SNNo;
MIOW 15 ANN. COMPANY.
ry CERTIFICATE OF VITAL RECORD
2 2 2002
IMMEDIATE CAUSE (Foal
disease or condillon
(esull rig •ineals)
Sequenllagy 11st -co d Ito
i! a y, loadinga"q_ mad le
cause: Enter UNDERLYING
CAUSE (diseasejorl jury II
tNet Initl led events
ra3vl(Ing n_ death)
I TE� OF ID AHO,';�;
IDAHO; DEPARTMENT OF HEALTH ANDWELFAR
REQU OF VITAL RECORDS AND HEALTHSTATISTI
DECEDEN' l
State of Idaho 516 5
CERTIFICATE OF DEATH
Slate Flla No
0 L cosy NIS DOWU CERrnd
[01 THE STATE nEOSown. 00000x00100.0ENt0.1. w L. SOU eE01 0 05 n
a> :.In) >9zT Local 'Reg, NO
AGE-- Last Birthday
MmDLE
Charles
UNDER 1 YEAR
MOHiHS .1 0005
INSIDE CITY LIMITS j' WAS. DECEDENT OF HISPANIC ORIGIN? (Specify Now Its
If yes pertly C ban; Af akan, Puerto Preen. eft)
❑Yes I Y4
INFORMANT, 5 NAME (fype/Pn I)
Cat eriae 'Ve Ann Veigel
dc�. 1. tl I
METHOD OF DISPOSITION..
Burial,
'1:1&en ❑Removal from Idafio
❑Donation ❑.other S ecif
(P Y)
SIGNATURE OF ERAL SERVICE LICE EE OR P ACT
I.
A
ld 3 0 2 200
DATE -ISSUED:
This copy Is not valid unless prepared on engraved border
displaying state seal and signature of the Registrar.
Veigel
UNDER 1 DAY.
HOOPS I MINS.
_PLACE. HOSPITAL .OTHER
�Y
MARITALSTATU* M iii d, Nev SURVIVIIon SPOUSE (It weeke,LLll yi ratigipel DECEDENT'S USUAL OCCUPATION (G' ki of rk d KIND OF BUSINESS IN_0USTRY
,�1arried /f CAd
Married. WIdered D1vo d S p e c l r y 5 eson during most of workln l i f e l se II d)
BIRTHPLACE MOTHER FULL MAI0EN NAME..
Fairview,
::,14 outing
I N
MAILING ADDRESS Street and Number or 001111 Rout! Number Ceele or i Slate, Zp Cod)
1266 Highway 236 'Afton, Wyoming -8
PLACE OF DISPOSITION (Name of cemetery, eremaroly or olfterptaceJt, LOCATION -.01ly' o1 Town; Slater
Afton Cemetery Af ton;
m za
OAS SUCH LICENSE NUMBER (07 Ucensee) NAME AND ADDRESS OF FACILITY
*.M -676 "Schwab Mortuary, 44
:IS :Afton' '.W
Year) WAS CASE REFERRED TO CORONER? MANNER OF DEATH. (Check Ore)
f,` Nalural ❑Homlcld(
❑Yes KINo ID Pending Investigation
DATE RONOUN. 0' DEAD (Month, 0
40 P .t ;,.July 6, 2002
27. PART 1 Enoter Ih O e r heart a UsLO es'in)urie arco nly one Rlplieallons c ause on Iheaal c h lin c ause e. d the death. Do not enter the mode of dying;:. such as cardiac a sp alory
shck b.-
MEDIATE CAUSE
DUE TO (aces conseque o0
rA7 r. rLitaJ
re etronseguenc000:
C G G 14 (fir• }ory 0 }ae LSG
-RUE 10 for as.A consequeno e o0. J
27 PART IL plh r Slgnitice t Co ndIllons contributing.IO death but not renulling In the underlying cause given (n
STREET: AHO_NUMB R ZIP COOE-
1266 ltighway -236 $31.1
This is a true and correct reproduction of the document officially registered and placed
on flle:avlth the IDAHO BUREAU OF VITAL :RECORDS AND HEALTH STATISTICS
Elementary/Secondary
RACE Aermcan d 01500. la 0ECE0ENT5. EDUCATION
J ap Wh,te, etc (Sp dy) (Sped fy ty high t Ared pl t d
White'
CERTIFIER 'Checked/5i
HYSICIAN 70 the best of my knowledgejdealli occurred at the lime,. date and plane, and 4 ue to,the eau as stale4-.--
D CORONER 0n the bas rs ami 1 dloElnvesligatio m.rpy opinion death occurresKallthe tlrne, dale, andpl ce and due Co the ea and mariner Os staled:
SIGNATURE AND TITLE OF CERTI LICENSE NUMBER DATE SIGNED (Month. O y Ilk
NAME AND AD00000 O F CERTIFIER (Typo/Print)
fl Mat,E 'Tannenbaum $1. Di. 3100 Charming Way, Idaho Falls, Idaho 83404
GATE OF DEATH (Month. Day," lbw) f-
July 6„ 2002..
BIRTHPLACE And SON :0l ,Forergn Country)
Fair-viety, Wyoming
tcnicx ono 1)'t Inpallenl 4 L on g Term Care ram ity' (6).❑ otherPdvate.Resldence
e>- ❑ER /Out alien) (3) DO
P O (5) Residence (7) ❑Ol her(Speclty)
FACILITY NAME AND ADDRESS (II Aot Ire p lal,, e. Of pia e, teat end number) CITY, TOWN On LOCATION OF DEATH COUNTY OFDEATH
.Eastern IdAlio Regiona1' Center Idaho Falls Bonneville''
'3100''Channin .17
PARENTS.
INFORMAN
DISPOSITION
C7.S>;Icide ❑Accident
Could Not Be Deterhtined
rest 'IAppio`kr" le
1 .6 1 !7. 1.
Beee O
'Iend alh set
tir„m�a
WERE AUTOPSY FINDINGS AVAILABLE.
PRIOR 10 COMPLETION 1:30 CAUSE
INJURY AT WORK?
❑Y 0 No
REGISTRAR
HOUR OF INJURY
IF TRANSPOH1jATION ACCIDENT SPo!ry 1
❑OriJe, Passenger ❑Pedeslnan
DESCRIBE HOW INJURY OCCUnRED,
CORONER'S ACTION
1. 1 have reviewed and/or amended, and certified.
REGISTRAR SIGNATURE,
PLACE OF INJURY AI home, lane, street,
Mdory. olece holding, e 0. (Specify)
CORONER'S SIGNATURE
LOCATION (51,, `w Rome, Hum.
DATE FILED
y
T,
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