HomeMy WebLinkAbout889290STATE OF WYOMING
County of Lincoln
AFFIDAVIT OF SURVIVORSHIP
889290
.)
) SS'BOOK571-S PR PAGE___
)
048
REOE VED
LINCOLN COUNTY OLERK
~" ,-t,.t :<i,:: '< ' :~'ii~ t'': :ti'
COMES NOW, Lisa Lee Mills ("Affiant"), and being first duly sworn upon her
oath, deposes and states as follows:
1. Affiant is the surviving daughter of and the surviving tenant of a joint
tenancy estate with respect to her deceased Mother, Karin Jean Mills,
and has an interest in estate property which is the subject matter of
this Affidavit.
2. Affiant states that Karin Jean Mills died on the 2nd day of March,
2003 at L.D.S. Hospital, Salt Lake City, County of Salt Lake, State of
Utah; the facts of said death more fully appear from the Certificate Of
Death, dUly certified by the State Registrar of Vital Statistics, State.
of Utah, attached hereto as Exhibit "A", and by this reference
incorporated herein.
3. That the Decedent, Karin Jean Mills, acquired the following described
real estate situated in the CoUnty of Lincoln, State of Wyoming, by
survivorship recorded on November 3, 1999 as Document No. 862384
in Book 437PR on Page 762 in the Office of the County Clerk and Ex-
Officio Register of Deeds in and for Lincoln County, to-wit:
Lot 7 of Block 3 to the Town of Kemmerer, Lincoln
County, Wyoming, as described on the official plat
thereof, being the same land described in Warranty
Deeds recorded March 8, 1985 in Book 224PR on page
455 and recorded April 5, 1999 in Book 428PR on page
184 of the records of Lincoln County Clerk.
4. That a Quit Claim Deed conveying said real estate to Karin Jean Mills
and Lisa Lee Mills, as joint tenants, was recorded on November 3,
1999 and recorded as Document No. 862385 in Book 437PR on page
765 in the Office of the County Clerk and Ex-Officio Register of Deeds
Affidauit O~ Surviuorship
Karin Jean Mills/Lisa Lee Mills
in and for Lincoln County.
0'4 9
That by reason of the above designated conveyance, and the
ownership as joint tenants of the interest described therein by said
Karin Jean Mills and Lisa Lee Mills and by reason of the death of said
Karin Jean Mills the above described real property became solely and
exclusively vested in Lisa Lee Mills.
This Affidavit is filed for the purpose of establishing the fact of the
death of the said Karin Jean Mills, who was owner with Lisa Lee Mills
of the above described real property, and to make an official record
of the termination of interests of said decedent in and
properties, pursuant to the provision of W.S. § 2-9-102.
FURTHER your affiant saith not.
[~_ day of April, 2003.
DATED
this
i
LISA LEE MILLS, Affiant
to said
STATE OF WYOMING )
) SS.
County of Lincoln ) .
Before , a Notary Public in and for Lincoln
County, State of ~.y~in~, personally-appeared Lisa Lee Mills and she being first
duly sworn by me upon her oa£h, says that t..he facts alleged in the foregoing
instrument are true:~~--~ ~~ I~~d~ ~.~ ~ ~ ~
· WITNESS my hand and official seal. !.3 ~-~.. ' '
} c~J~O~ ~i~ ....... } ~o~ Public
} t,uca, ~¢~¢:1 ~0~,,~ I My commmmonexp~res:
Affidavit Of Survivorship
Karin Jean Mills/Lisa Lee Mills
2
1.:NAMEOEDECEDENT FIRST .MIDDLE'!; · LAST 2 SEX 3a DATE OF OEATH (Mo Day Yr) 3b TMEOFDEATH 24hr
"Karin J~an '':: :Mills: ': Female I March 2, 2003 I 0800
4DA, TE.OF'.I)IRTH(Mo.,Oay, Yr.)~ S. AGE;Ea~tBi~*~:~ay '!FUNoERIYEAR i~L~O~,-R~4t~$. 6 BRTHPLACE(Cd),&SaeorForegnCounG,) 7'$OCALSECURTYNUMBER
2 (~ ~ ! 7 J~ I Kemmerer, Wyoming I 520+-50--i4~0
B~; pLACE:[H0~pITALi~iemsm~e~ H~./~/yJ:!ALE 0THEBLOCAT 0NS! 8~ NAME OF HOSPTAL NURS NG HOME OR OTHER FAC Lffy
E~Oupa en ~3 OOA: ::~::70fieit~p~) L D S HOSDJ
:~ :;~?~:' < .':: ~: Ke~erer Lincoln
~ ~..~.om~ ~'4.o~, s~ ~ite 1 ~ :
H. ' Safina K, RgbgFts : '
ONSHIP ~D MAILING ADDRESS OF Nff0RMANT
:7: Li~ Mills WyominK 83101 (Daughter)
2. Donalion ~ 3. Other ' , · :;.;.
-'~3!U3/zugj, Ke~erer Cemetery Ke~erer, Wyoming
~.~'URE~ON~ UCENSEE, 7;; :: 23' LICENSEE NUMaER 24. FUNE~ HOME ( ..... ~ ~mss) ; :]
:~~ : (:[ 1:115198 Crandall Funeral Home~
~5. OAV/DEC~SEDWAS~ST 2e .0~d~6dbym~di~xamne, wasde.~ e~,ed oMET~ Yes ~ a No 105 East Center Street
~EO BY CERTIFYING PHYS CAN yes ener he'da eand~urfep~ed ~ ~ .. -- , ~.~.
PHYStCI~: To th" bes~ o[ My ~Jedge, ~ea~ ~ed el Ihe I~e, date, and pl~, e~ ~e lo ne ~use(s) and manner as slated· · '
J. WalSh 32:4 i0th Avenue Suite 206 Salt Lake City, Utah 84103
' ~ ~ Mmr~h 4~ 2~] ' ·
O~S~SES, ~NJUmES 9.~ 9OMPU~ONS THAZ CAOSEO ~HE O~TH DO NOT ENTER THE MODE OF DY NG SUCH AS CARDmC I~
~: ~ ~ : ;~; J~R ~SPI~YORY ARREST' SHOC'~ OR H~AJ[URE' 7LIST ONLY ONE CAUSE ON ~CH UNE I~nOnsetand
~mg~S~e:~mli~n'hat, D"~.TO (0" AS A CONSEQUENCE OF:
' ':: .. '. ::: .: ;:
:.' 3sa. DAT.~ !N~R7 (~.~O~..yrJ ~b:~)~y 3~. tNJURYAT~RK? 3~. P~CEOFINJURY-~home ~r<
Investigation 35g. dE,CronE HOW iNJURY OCCURRED (e~er sm~e ~ e~nts whi~ msu~ in in~. NA FURE OF ;~JUR Y s~ou~ be ente~
i~:'a::trUe copy Of the:~sriifi~i~'Jn fiji'in this off ce Th s certified copy is issued
:'2~-;2;-22 of thC Utah CS:d~ Annotated ij953 As Amended
·. ': : r ":'::: :';DIRECTOR OF VITAL RECORDS
* 0 I 2 3 4 8 4 6 *