HomeMy WebLinkAbout889952THE STATE OF NEW MEXICO )
THE COUNTY OF'/~A~F}~)~ )
8P, 9952
LIN,}01_?,.I 0(}Ut..]T',,/ 0LERK
AFFIDAVIT TERMINATING ESTATE BY THE ENTIRETIES!'i' '"". ;"':i i ':' !' i
I, Janet Gayle Mecca, being of lawful age and first duly sworn according to law,
upon my oath, depose and state:
1, That I am of adult age, a resident of Moriarty, New MeMco, and the
Affiant herein.
2. That by virtue of the conveyance whici~ is recorded.in th~. o,,,~e of the
County Clerk for Lincoln County, Wyoming, located &t Kemmerer,
Wyoming
in Book 481 PR on page 650 is recorded a Qui~
Claim
Deed.
The Quit Claim Deed, dated the 29th day of December, 2001 conveys
unto John B. Mecca, Donna L. Bertot and Janet Gayle Mecca, as Joint
Tenants with Rights of Survivorship the following described property, to-
wit:
The East half of Lots 1, 2 and 3 and the Northerly four fe
Block 5 in the Fairview Addition to the Town of Kemr
County, Wyoming as described on the official plat there¢
LESS AND EXCEPT the land contained in Quit Claim Deed
10, 1997 in Book 398PR on page 123 of the records
County Clerk
That said Donna L. Bertot died on the 27th day of Januar'
B. Mecca died on the 19th day of April, 2003 and a copy
certificates of death, certified to as true and correct by p~
in which the original of said certificate is a matter of recor
hereto as Exhibit "A".
That by reason of deaths of said Donna L. Bertot and John
by reason of §2-9-102 W.S. (1980), the decedents interE
said conveyance has terminated and title to the real propE
thereby has vested absolutely in Janet Gayle Mecca conti
the deaths of the said decedents.
FURTHER AFFIANT SAYETH NOT.
et of Lot'4 of
~erer, Lincoln
f.
ecorded June
~f the Lincoln
', 2002, John
}f the original
iblic authority
d, is attached
B. Mecca and
st and title in
~rty conveyed
nuously since
State of New Mexico
County of
Gayle Mecca
The foregoing instrument was subscribed and
Mecca this ~ day of May, 2003.
Witness my hand and official seal.
OFFICIAL SEAL
THERESA DANBURY
My Commission Expires:
sworn to me b
Janet Gayle
N~t~] ry Public
r'o5
~ :':.
(NOTE: If death is due to accident, homicide, trauma, or
unknown causes, refer base to Medical Invesfiqator)
First
..... :JOhn
DATE OF BIRTH (re01 clay,~::::: y?) ::::.::::::2 AGE- last~birthday
DECEDENT H SPAN C3 ::::~:::: ~ i[i;:;;;
Spanish
I NO []Y~S SPUc!fY: []
Certified by Physician :~ Bernalillo Albu(
County of Death City, Town, Location
Middle Last b ;~ G SEX DATEOFDEATH(mo, day, yr)
Batista MECCA z M.:a~:;:~:A:pril 19, 2003
] UNDER 1 YEAR [ UNDER 1 DaY I RACE - Specify White, Black, Native :.i':::: IE:~ATIVE AMERICAN, Specify Tribal
Amer can elc ::: : ::: Afl a on (e g Z a J car a Navalo · c
/ Mos. DAYS / .OURS M,NS./ ' ' .:::::1 ::~::~'~::::1 .... " '
hs~:----r ..... 1=c-7--1 ..... -t0a. White :::: ..... U::::l'db:
EDUCAT ON O~ 0E~EOENT::~i]ndicale highest grade
Mexican Cuban Puerto Rican Other completed I ::'.;:ii:.ii:i;i::
[] [] [] [] Specify 7. 0 1 2 3 4:5::8::7::8 ~(~10 11 12 13 14 15 16 17 +
PLACE OF DEA'[H L Nam~ of hgspilal or other facility [if neither, give slreet and number or location)
HOSPITAL ; :: ..::: :7 OTHER
[] )np~,tien/ :: ::E] ER/Outpatient [] DCA
STATE OR COUNTRY OF BIRTH WHAT
':: :: ::::' COUNTRY
10. U,S.A,
SOCIAL SECURITY NUMB'ER: :
520~03~1798
RESIDENCE - state :: Cbunty
~6a. Ne~:;;:Mexic$ !::::: t6b.
I
MARRIED, NEVER MARRIED, {SURVIVING SPOUSE (If wife, give bir~h name)I
WIDOWED, DIVORCED - Specify I I!i::::::::::::::::::::::::::::::: U.S. ARMED FORCES'
~UAL~oJcduO~A~T~IO~Nd(Kind of worLld2(;ne during moSs/)working lif ...... if reti~} ::::: :::K ~0::'~¥ ~U~'~ESE~S ;FRS ND~u~TORy
,5.. Welder :,:s~. Mining
City, Town or [ocation :~ } :.: ::: 5:i:~ INSIO~ Cl~ UMITS?
Torrance I~=. Moriarty ::?:: ?.::: ~ i,~a.~[s ~o
STREET AND NUMBER OR LOCATION : ,:,: :. :::
~e. 202 Tulane North
FATHER - NAME First Middle Last
James N/A Mecca
INFORMANT - NAME (Type or print) MAILING ADDRESS Street/RFC No.
,g~. Gaff Mecca It0b. P.O. BOX 493
METHOD OF DISPOSITION
Burial [] Cremation '~'R~moval from Slate [] Donation [] Enlombment [] Other
(Specify)
20a.
LOCATION :: City/To~vn State
MOTHER * BIRTH NAME First Middle Last
Virginia N/A Coletti-
City/Town State Zip
Moriart' Ney/ MeXico,
CEMETERY/CREMATORY - Name
2ob. South:Lin6o n Cemeter'
JCENSE/or PER~ ;H q sigfi:atum LICENSE NUMBER
200.
FACILITY - NAME :
%Street/RFC No. City/Tdwn ' i State
2~o. French MOrtuary'
CERTIFIER'S SIGNATURE On the basis ot examine ion and/or
iann~s;ilag::oar,~ndumeY ,Ti,~iec ;;~sa;(hsF:tCalre~~ a.~)t'm?Te
22a. _~,~~-~ ...... k' ...................... :2f~.:. ......
22b. ADDRES~ : ~'l O¢-' (', ,./~ ".) ~:./V' ,;~L,~i.~ ~
DATE SIGNED (mo, day, yrJl HOUR OF DEATH
PRONOUNCED DEAD (mo, dayl yr)PRONOUNCED DEAD (hour)
20015 =. 0245 hrs.
MANNER OF pEAT.
NMVRHS (mo, day, yr) I
cause of dealh?
:~ YEs: i [Si~NO [] YES [] NO :i!: i !ii: ;ii~!:i: :.i i::
24a. 24b. 24c. :
,tED (CITY, STATE)
WAS RECENT SURGICAL:::,: 1 IF YES, SPECIFY TYPE OF PROCEDURE
PROCEDURE PERFORMED?
25a. [] YES ~xlO 25b.
DATE OF PROCEDURE
25c.
etc. · LOCATION : (i 5 :sire~tJRFD Nb '::i;
:' :::: :.' i: : 1! : ': : '. ': ::: ':: .: 7:: :.:
: ::': :::: ·. 2~f! ::::'::i::::':'. ::7::' ?!'i:
28 · :.PART h Ente? the diseases, injuries or complications which caused the death. Do not enter the mode of dying, such as J i!::: :. : :::
:. :: cardiac 0r respiratory arrest, shock, or heart failure. List only one cause per each line. i::' .::: ! F:.i
If yes,
length
26b.
Approximate inlerval
between
disease or cdndition .... :::::::: ::
resulting in death.) ~ a DUE TO (OR AS A CONSEQUENCE OF): I ..: ·
1 CLI:'IF i: ::::::-:.
: :::::::::::::! ~::: C--~ e~,'.,:,.,--,..i A -i -b,.e-~.~. ::~: :1: ::. ::[i %::
.... Sequenlially Ist conditi°ns,.~ DUE TO (OR A.~ CONSEQUENC..~ OF): :::; :i [:
:::::ff any, leading to immediate ~
CAUSE::cause' Enter(D sea~UNOERLYor inju~NG c ~-" [4 f~ { ~ j~-~4C'~ ~'4 ~ ::: 'j::~: :~:: :::~: ::
Whibh ~nitiated ~vents DUE TO (OR AS A CONSEQUENCE OF): :: i::] :: .: :"
resultin~ in ~eath)~ST :
: :::::';:: ~;; ':~ ; ·d. ':
PART II. Other significant conditions cohtributing to death but not resulting in the underlying cruse given in Part I.
SHADED AREAS FOR MEDICAL INVESTIGATOR - LEGAL OFFIC
(.)~_~,~]~, CERTIFICATE OF DEATH (OVEP~$EA$)
Acre de d6c~s (D'Outre-Mer) ,~ ~
NAME OF DECEASED (Last, First, Middle) Nora du ddc~d~ (Nom et pr~noms) GRADE Grade BRANCH OF SERVICE ] SOCIAL SECURITY NUMBER
Arme I Num6re de I'Assurance Sociale
BERTOT, DONNA L. DODDS Employee 520-50-1973
ORGANIZATION Organisali0n NATION (e.g., United States) DATE OF BIRTH SEX Sexe
MANNHEIM HIGH SCHOOL Pa. Data da nai ......
L_J MALE M .... lin
UNIT
29939
APO AE 09086 U.S. · 28 FEB 46 [] FEMALE
1 CAUCASOID Caucasique SINGLE C61ibataira DIVORCED Catholique
Divorc~ Protestant
NEGROID N~grOida ~ MARRIED Mari~
SEPARATED
OTHER ISpecifyl WIDOWED: Veuf S~par~ JEWISH Juf
Autre
NAME OF NEXT OF KIN Nora du plus proche parent RELATIONSHIP TO DECEASED Parent6 du d~c~de ave~ le sus~it
DOUGLAS BERTOT HUSBAND
STREET ADDRESS Domicil6 ~ (Ruel f CiTY OF TOWN AND STATE (Include ZIp Code) Villa {C ode postal compels)
KEPLERSTRASSE 26 ~ ......... 6~C1207 ~SAN_DH~A_U. SEN GERMAN~y._~
MEDICAL STATEMENT Daclatation m6dicale ' '
INTERVAL BETWEEN
CAUSE OF DEATH (EJ~er ont~ o~e came ptr line) ONSET AND DEATH
Cause du d~c~'s IN'indiquer qu'une cause pat ligne) Intetvallo entre
{'ertaque et le daces
DISEA'SE OR CONDITION DIRECTLY LEADING TO DEATH
Maladi ......dition di,ect .... t ,.p .... Ue de ,a ,.on.~ PULMONARY EMBOLISM 2 HOURS
I MORBID CONDITION, IF ANY,
ANTECEDENT LEADING TO PRIMARY CAUSE DEEP VENOUS THROMBOSIS 14-3 DAYS
CAUSES Condition morbide, s'il V a lieu,
manant b ia cause Primaire ·
Symptbmes UNDERLYING CAUSE, iF ANY,
GIVINGRISE TO PRIMARY
pr~cufseurs CAUSE
de ia mort. Raison fundamentals, s'il y a lieu,
ayant suscit~ la cause primaire
c°N°m°NS'~- - GIANT INCISIONAL HERNIA REPAIR 4 DAYs
~NIE,CXNT
~ ' PERFORMED Autopsie effectu6e [~ YESDui [~[ NO Non CIRCUMSTANCES SURRO JNDING DEATH DUE TO
[~ EXTERNAL CAUSES
~ ND NGS OF AUTOPSY Conclusions prlncipalea de I°autopsie Circonstancee de la mort uscitees par des causes exterieures
THOLOGIST Nom du pathologiste
SIGNATURE Signature I DATE Date AVIATION ACCIDENT ~ccident ~ Avion
[ [] YES Dui [] NO Non
DATE OF DEATH (Hour, day. month, year) PLACE OF DEATH Lieu de d~c&s
Date da d~c~, a'h ..... ~,~oe,. ~, ,,oi,. r,,,~,) I HEIDELBERG, GERMANY
20:37HRS 27 JAN' 02 I
I HAVE VEIWED THE REMAINS OF THE DECEASED AND DEATH OCCURRED AT THE TIME INDICATED AND FROM THE CAUSES A S STATED ABOVE.
J'ai examin8 les restes motto s du d~funt et je conclus qua le d~c~s est survenu /~ I'heure indiqu~e et }. la suite des causes 8nun 6r6es ci dessus
NAME OF MEDICAL OFFICER Nom du medicin militaire ou du mddicin eanJtaire TITLE OR DEGREE Titre ou dipl6rn~
MARTIN H. TIEVA, COL, MC GENERAL SURGE°N
GRADE Grade INSTALLATION OR ADDRESS Installation ou adresse
O-6 U.S. ARMY MEDDAC-HEIDELBERG, GERMANY CMR 442 Apo,,E 09042-0130
JANUARY 29 2002 //~
/ State disease, inju~ or co~licmion which ca.ed demh, bm nnt ~e offing such ~ h~failure, etc.
2 Stye co~itin~ contdb~ing to the de~. bm nnt relmed to the di$eme or co~ition ca~g dash.
t ~ci~er la nmure de ~ md~ie, de la ble~sure ou de ~ co~lic~ion qMa com~bud fl la ~, ~s non in ~i~re de mouHr, tellt qu '~ art& du coeur, etc.
2 Praiser la co~ition q~ a contHbu? ~ la man, ~ n'~am auc~ r~pon av~ la ~l~ie ou ~ la co~ition q~ apro~qu~
"OD FGRM ~gl~ P~PR lg77 RE~,~CES'D~FOR~3~ff9: t.lA't't ?97~AN~DA'FeRM3585-RfPA~; ~eSEP ~S75:W~GS3~E~ ~ISAPAVI.00
(REMOVE, REVERSE, AND RE-INSERT CARBONS BEFORE COMPLETING THIS S1D
DISPOSITION OF REMAINS
NAME OF MORTICIAN PREPARING REMAINS ; GRADE LICENSE NUMBER AND STATE I OTHER
INSTALLATION OR ADDRESS DATE , SIGNATURE
NAME OF CEME~:ERV OR CREMATORY LOCATION OF CEMETERY OR CREMA'TORY
TYPE OF DiSPOSiTION [ DATE OF DISPOSITION . .
[] BURIAL '~:] CREMATION' [] REMOVAL ($.Oee/./y) 'I
REGISTRATION OF VITAL STATISTICS . ·
REGISTRY fTo~ and Cot, u~lry) · ' DATE REGISTERED I
......... FILE NUMBER
STATE · I OTHER
NAME OF FUNERAL DIRECTOR 'ADDRESS
'
SIGNATURE DF AUTHORIZED INDIVIDUAL ' '
2064, APR ;97? (BACK) ~'
USAPA Vl.00
THIS A TRUE CERTIFIED COPY OF THE ORIGINAL DD FORM 2064 ON
BERTOT, DONNA L. 520-50-1973, DODDS EMPLOYEE
CPT, MS
Chief, PATIENT
ADMINISTRATIO~