HomeMy WebLinkAbout888612RECORDING REQUESTED BY:
Law Offices of Anne M. Campbell
P.O. Box 5753
Vacaville, CA 95696 -5753
WHEN RECORDED MAIL TO:
Law Offices of Anne M. Campbell
P. O. Box 5753
Vacaville, CA 95696 -5753
STATE OF WYOMING
COUNTY OF LINCOLN
ss
AFFIDAVIT
Page 1 of 2
RECEIVED
LINCOLN COUNTY CLERK
O3
2I
BOOK 515 PR PAGE O 3 2
STAR VALLEY RANCH PLAT TWELVE (12) LOT SEVENTY -ONE (71) AS
PLATTED AND RECORDED IN THE OFFICIAL RECORDS OF LINCOLN
COUNTY, WYOMING.
9: 2c.
JAMES E. BARE, being first duly sworn on oath, deposes and says:
1. That he resides at 2619 Orchid Street, Fairfield, Solano County, California 94533, and
is the surviving son of Jack L. Bare, deceased, who died on November 12, 2002, and Jeanne E. Bare,
deceased, who died on February 11, 2002, in Folsom, Sacramento County, State of California (the
"Decedents
2. That the Decedents, as Grantors and Trustees, executed a Warranty Deed pertaining
to "The Jack L. Bare, M.D. and Jeanne E. Bare Trust of April 15, 1994" (the "Trust
3. That the Decedents transferred to themselves, as Trustees of the Trust, the following
described real property situate in Lincoln County, State of Wyoming, to wit:
0888612
4. That pursuant to ARTICLE NINETEEN of the Trust, upon the Decedents' death,
resignation, incapacity or disqualification, then your affiant, James E. Bare, is appointed successor
Trustee of the Trust.
5. That upon November 12, 2002, the date of the last Decedent's death, the affiant,
James E. Bare, became successor Trustee of the Trust.
6. That your affiant is now lawfully serving as the sole successor Trustee of the Trust
with the same powers and discretions as originally conferred upon the Decedent
Dated: 3 //3
State of CALIFORNIA
County of SOLANO
otary P blic
Commission No: /3 5
ss.
Ja
JURAT
My Commission Expires: a 35 e 2OD (,o
Page 2 of 2
are, Successor Trustee
533
James E. Bare, Successor Trustee, subscribed and sworn to before me on this /3 day of
March 2003.
KAREN M. COHICK
.?;3l `t COMM. 1358714
M ��R ARYPUBUC- CAUFORMA
5 9. SOLANO COUNTY 0
COMM. EXP. JUNE 25, 2006"`•
v v rv^� v w ry
[seal]
DECEDENT
PERSONAL
DISPOSITIONISI
STATE OF CULIOI;NIA
CERTIFICATION OF VITAL RECORDk
Thls =la a Prue _anaexa9 r_eprniduction of th document offlciallylegistered and placed: or
:fife :With SACRAMENTO COUNTY DEPARTMENTOF }1EALTi-FAND HUMAN SERVICE
PAR TMENT I 'OF HEALTH AND'.'H
C Eft TI F I C ATEL.OF ,DEATHiV,
p I STATE OF CALIFORNIA
ERASURES,. W A 1
II USE SLACK IN) ONLY�NO, HITEOUTSIOR LTERA4'IONS
(REV. 'I/0 I +j.
1 1
AL REGISTFjJ�TIQN JUN
J Nk• 'p is��
NAME O E F T (O
7 DATE OF. DEATH 11
,1 EDUCATION YE
4, DATE 0 0 5 4 1 (1 0 0 0 0 C.9 Y.
41/- 22/1919
5 AGE •YR IF UNDER 1 F I UNDER 9 HOURS
MDNTHE I D HOUR 1 INUTEE'
ECURLTY1D;"
20-5EEIDENCE— (STREET AN0 SUN9ER�k 1
,.2619 Orchid
PpuOE =Fii
UCf A THER-
_IOI. !4LAOE PF.f EATH 1'.
Folsom Cgnv 41
E 27...MA(LI
(05.IS 4 0.ET ADDRESS— (S AND NUMBER OR LOC971p11
S10 Mi11 :Streets 1
19 ATH WAS,CAUSED BY ENT1=R ONLY Off{ CA�JSE ER LINE'FOR A.1
B: OF•BUSINE55";
Health _Care
Y (1 PLA EOF FINAL I,115 SITIONff`f.; t j 4 4A F
Mt, Vernonm.Memorial Park° i 8201 ;G'een J, ck
NUMeIR,oR;!IURA
X103 F R.R
'CRAW' °4ITAL_
rteri.os ersi
112 OTHER SIGNIFlFAN� COND TI NS- CONTRIBUTING: T0 DEATH RUT NOT RELATE14 CEN :JN 1
Ij I.•nl 1 ...•1' .f=.� d kJ 4 AUSE GIV .yrd; 7
Post Ce rebrovas:cuiar "Aceid_ent_, Diabetes Mellitus
11 3. .WAS OPERATION PERFORMED JJH'AN ON01T( T TYP�OF 0500*TID
121::1 NJURY DATE M M D D C'C Y N
122. HOUR
g0 •1 l( )RTIFY TH•AILIIN M1, OP NION DEATH
OF URRED ATI THE HOUR, DATE ANO'.PLACE,
1 VISTA EO FROM�THEI CAUGEG STATED.
1 rr P F.pEATH I.��
(2 0. 51GN IY11C950l R
27. DATE
Iif9ME TERYA4j;
DETWEEN,ONSET,
13EAT113
REFERRA4 N�Me
.109 .BIOPSY PERFORMED';
USEO.IN DETERMR(ING4AU5
14:31.1-1172111,3 07 OR I12I :IF'YES
472
30. BIRYD .STATE
124 DE CR IRE HOW (NJURY, OCCURRED (EVE WHICH RESULTED;-1
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ATE FILE N UMBER
r.,1. 4i4ICAE. OF LOE E N F
Jeanne
:_INFORMANT
DUE -;r o"
D ATEISSU
21 CITY I
Fairfield
26. NAME, RELATIONSHI
James Bare',
20.'NAME OF SURVIVI
Jack
510 Mill Street
814rDWEST; BANK: NOTE COMPANY`
20 RESIDENCE TREE7AND .NUMBEfl
31 NAME 02 FATHER.- 'FI
Stanle
!35 NAME O,F MOTH -F1,
Florence f
39:' DATE M'M J O D C C ;,V.Y.
02/14/2002 t rai l
:4t TYFE OF DIS0o9rl
Burial 5 "P
Q4 NAME OF. FUNERAL 01RECTOR 11
Mount Vernon, Mortuar:'
WAS OPERATIO�J:'PERFORMEO EO
114 I I. CERTIFY TNAT TO "THE BES KNOW
EDGE DEATH U
OCCRREOA l
TTHE10UR :D
AND LACE STATED 'FR M THE CAUSES. STATE
DECEDENT ATTENDED SINCE I DE EDENT LAST SEEN 'AU
MM /)l0 /CCITY MMJ D� /CCYY
15/'1988:.. 101/25/2002:
CERTIFY 10 42 I0 MY OPINION DEATH
'il lr1 O CCURRED AT THE HOUR,' DATE AND P,LAC
ISTNTEOT..FROM THE CAUSES STATED.
11 MANNER OF I DEATH I
NATURA I ID
L: SUICIQE
I I I!
PENDING
L_J.:.ACCIDE141"11 INVESTIGATION
CER T IFIGATE OF D EAT I1 1
USE ,'STAT
BLACK 11410 ONLY/NO ERASURES; WHITEOUTS OR ALT
5. YRS.
I
N M CIDE
COULI NOT SE
DETERMINED'
R„OR LOCATION
PUTT CORONER
0. KIND OF.BUSINESS-
Own Home
oiano
-WAG, CAUGGIDT'IS y VENTER NLY QJ� €„�AUSE F ORA,
NDITIONIIN ITEM
1 i.; MILITARY
42. (SIGNATURE
SERVICE
Yes .L No
R HOURS
s. :MINUTES
.,9
ailliovascular. Disease
NOI TIONS CQNTRIeuT NG,TO =DEATH OUT NOT`RELAT0I1_t0 0005E 0
tus; Mye1ody.splas ia
33:_LASL
Haas
37,: LASTI MA10EN1
0ldridge
103. FAEIL)TY OT ER:TII N'HOS
3 LA I0A L
Bare;:
2 MATIITAL STATUS;
,1 24 DESCRIBE HOW INJURY pCCURREO (EVENTS 1(J
-16:' USUAL EMPLOYER
el'F
OR!'.I 12T:_IF _YTS; LIST'TYP1._ OF OPERAT. O NO.
3. CO
CO
acramen
Folsom
128 TYPED 'NAM TITLE.OF COR NER O I
QCGU7
rE O9 FOREIGN,LOUNTRY,
3 4'jzty, y R,OIATE
ansas
TR. E <INTERVA 100 "'DEPTH REPORTED TO CORONER
Tr* N ONEET
AN D ATHpq I�yI!
41
IS 51G ATUR A T LE O CERTIFIER 1_1 LICENSE A 7 DATE hl 1410 D 11
.G-:032946 02/11/2002
I I0. PE ATTENDING PHYSICIAN'5 N ME MAILING ADDRESS =IP 95
Donald Gutman M.D. 1600..Creekside:Dr;; C A`
CO i7NTY OF SACRAIV1 NTO ;al
Th s is a true and exact reproduc of the document officially registered and placed
fde with SACRAMENTO COUNTY DEPARTM QF. AND HUMAN SERVICES
Feb ruary 14 2002 LOCAL REGISTRAR
This copy not v prepared on engrave border displaying date and signature of Registrar
`I
:T7;
STATE OF CALIFORINTZ
CERTIFICATION OF VITAL RECORD
Tv"