HomeMy WebLinkAbout892391Affidavit
County of
;s
noo 5,3QpRp'AO 388
892391
RECEIVED
LINCOLN COUNTY OLERK
C°mes N°w, ~O YTa'. ~ /"~. '--,'/D ~" . Upo,] first being duly swo,',,, u4Jo~¢~. ~. ~at!.~/A~
Deposes ~d Says: - / - ' ......
21 years and a resident of ~5'7
That '~ O 7/Et_ ~ ~7"~ c7,/d'Y is tile surviving joint te,,a,,t of ,/9~ L//d /z/~ ,7",~'
who passes away on /,~ ~'~7/. a.'7o0_-'9__ and whose dead~ is evidence-by attached certified
Certificate of Death.
TI,at D¢!/~J // '/'4_~,~r whosedcafl, isevidencedbydmabovedescribedDeafl~
Certificate is one and the s~n'e person as ._/'~E2//i d /-// 7"d:7 ~/O,V one of the
/ '
joint tenant owners oflhe foilowin~ described parcel of real property described on the
~ar-F~-f~ Deed recorded ~/'~//~? as Entry Nmnber '?0'?~7'~ Book
,~-7-7 ' page ~0 7 Official ~,~~ Count.,.' Records.
/
That under the Joint 5e~mncy Laws of the State o f--~, __~_.onzC~
is the surviving Joint Tenant oft,e above descr bed properE/, and as such, is tl~e sole
owner of the property.
Date
Notary
State o f'"~J~ )
L-1'71¢01'~I ) ss. I kln¢6ln ~.~ Wyoming ~ '
si=net ot the withi~ instrLLment who duly ac~owled~~he executed the shine.
No,ars,~
My Comm~ssmn eXD~res:~ ~ ,
-
I 0
]Male I Jan 14, 2002 ~ 01106
2059 West 1800 North
· i i: ~::,~. ~:~:: · . ·
DECEDENT '1 st. George ~ ':':!" :; ::~. Zona ga're ._ .~
~MEOFORCES? : ~1, Ne~erMame~ ~ 3 ~d~; ~ :: .. : ~: '
' ' ~ ' ~ :~;:';.;:'~;r:::;:: ~l~an~.~ployee HAll Air Force Ba3e:
2059 west i8~0 :N0rth;~ ::/ /;;~'~r~:~ ~¢~;~;j~;~j?~>j~:r~{;~f?;~ ':s {:) '
.~.: ~L: :: ~. George Washington
,: ~ I:Anna Elizabeth Henstra
:: ' I ~omb~~ ZD0nal~
~ ~ ~ ~' A~tore~t ~ .... iai park Ogden, ~T 84403
.25. ~AI~UEU~SEDWAS~5~ ~u;[~not~mn~ym~:examner wasoeamre~,ea ~ ~z~
~~/,j ol DAY J~ Y~ ~S~. George, UT 84770
27a, CER~FIE~ : ,'.::: ~ ,', ' ': :~ ~:: ~ ~,f/: ~ ~ ~':~.~:~ ~f ~ :~: ~ ::~?~;;;.: . ·
CERTIFIER ~ ~ MEDI~INER/~WENFORG~.OFEIC~ 9Q~99~l~ff~~gal~.~my~ ~edat~e ~e, ~.pl~ ~ddullo
~ ' :~ ;: . .: ;
; :
' d.~)~ST : '..::: "~: ' L::': ' ' i ::::: ~:::: -:::
34, MANNER OF D~TH . :: F35~· DA~ 0[)~,~:(~ '~¢~'~J: 35b.TIME OF INJURY 35c INJURY AT ~RK? 3~ P~CE,OF INJURY;At home
· ' ' ; ' ' f
3~e :~ ~:'~ ~:~':~/ ::..:~:] ~ 1. Yes ~ Z N=
This is to certify 0~fJCe. This certified is issued
~,: unde~ authority Of
:.:: ~ County : e
~ ~-~,0~ VITAL RECORDS .: ::::
:~": : ?,:::!::: :',::
* 0 0 9 4 4 5 6 2 *
THIS AFF DAV T FORM CAN ¢
m~o.eot_ Correclio~$ and T
4.
e~, s~h ~ ~e rune~
6,
7.
~fi~ ~py ol the amin~d dea~
27-04~
O~NALLY
A A.I~ND RECORD
OATH OF F1RE, T
WITNESS
I hereby c~rflf
' FOrt USE OF STAT~
: This is to ~:eHif~ that thi~ i§: :~:
~ under Buthor ty of sect on:2
m Date ssued''JA ,- %
~ '. ' ~asn'lng~o
::.':: ~ County
::~::.:. ~:Registrar ,:': · .: :
abOVe
ADDRESS
DAT~ AOCEF
ICE OF VITAL RECORDS AND STATISTICS A RECORD
! ON J~J~T.J;;L~ L, AL-D. EA~[]:L[~J~-.CORDS 1989 TO THE ~
our office according to fhe In[ormeUon on ~e g~gi~l¥~0~d, eVel'
n a8 il's~dd ~ve ~ staled al me time of dealh. Pleue ~ or pdm
r ~i~M ~.~ ale r~ulred. G~ ~ce lo pre.re a rev~d, affi~
T~ ~flerent ~m~ ~o ~ve ~m~ k~ge ~ ~e a~ra~ ~ ~e
~h 20). The affida~t may ~ ~e b~ ~a ~m~'al~ng ~e er.
f ~e ~a ~fo~ The mla~ ~ , ":.
~[i~ S~tUs s~ be refeffed to ~ s~le 0~. ~ ......
n ~1 ~. ~W. The 'gnalo~s .~m. ~et. m~"~"i~ f~'~...
U'lNa O~,ce of Vl~l ReGOAdS and Sb~J~JcS. 288 NO,lb 1460 WeSL P 0 ~x 141012. SLC,
- ~ F~AL D~
N~E ~TATE CER~FICATE NUMB~
.1c LAST N3kJa~
' Taylor
PLACE OF OCCURRENCE - ~ InCl ~oun~
St. George Washinqton
MAIDEN NA~E OF MOTHER
Anna Elizabeth Henstra
~IECTIoNs ABOVE THIS LINE
2002
?~:' ,:~ '¥:::., .:
3HE PERSON WHOSE
al
thi~ office. This certified copy is issued
953As Amended.
VITAL RECORDS
* 0 0 9 4 4 5 7 2 *