HomeMy WebLinkAbout892401AFFIDAVIT OF SURVIVORSHIP
STATE OF WYOMING )
) SS.
COUNTY OF LiNCOLN )
B92hOI
BOOK ~30pR PAGE___
433
RECEIVED
LINCOLN COUNTY CLERK
I, DOLORES J. KOMINSKY being of legal age and first duly sworn, deposes and says as
follows:
1. That David K. Kominsky, the decedent mentioned in the attached certified copy of the
certificate of death, is the same person as David K. Kominsky named as one of the parties
in that certain Warranty Deed dated April 22, 1971, executed by C. D. Morrow and Eugenia
C. Morrow to David K. Kominsky and Dolores J. Kominsky, husband and wife, recorded as
Instrument Number 430147, on April 27, 1971, in Book 94PR, Page 27, of the Official
Records of Lincoln County, State of Wyoming, concerning the real property situated in the
County of Lincoln, State of Wyoming and described as follows:
The westerly twenty-three (23) feet of Lot Four (4) of Block Forty-
Two (42) of the First Addition to the Town of Kemmerer, Lincoln
County, Wyoming, as surveyed, platted and recorded, subject to
reservations and exceptions of record.
2. That I, am the same Dolores J. Kominsky mentioned in the above referenced Deed and
thereby am a person interested in the effective property or the title thereto and pursuant to
§ 2-9-102 W.S. (1980) hereby make the death a matter of record and certify that upon the
death of David K. Kominsky, his previous estate in the property was terminated.
That the certified copy of the certificate of death indicates that David K. Kominsky died on
February 28, 2002 in the City of Salt Lake City, State of Utah.
Dated this
..... day of August, 2003.
DdLORE L4 :d IN'SKY '
STATE OF WYOMING )
) SS.
COUNTY OF LINCOLN )
2003.
SubScribed and sworn to before me by Dolores J. Kominsky, this
My Commission Expires:
day of August,
................. ~ ~ . ::~ STATE OF' UTAH - DEPARTMENT OF HEALTH
................... '~"""""'"""~*'LOCAL .,LE NUMBE. 18]'~]2~ ~(:i:':' C:ERTI FICATE OF DEATH
one) ~ ~2, E~Oupaien~:~3:,Dq~..-~ ~.~ 9~he~(~p~d~).L I Un vers ty Hospita
s.,t m Dolores J,,an Bert.an. IH
6]6:Saphire St'~'ee:t..:":
' 8~036 ,:? , 'White 19
616 S"Phire Street Kemmerer. Wvomino 83101
SIGNATURe OF FU~L:SERVICE L~NSEE'¢~,~F~?-~-:~:~.~::~;-~:~J23 LCENSEENUMBER J24. FUNE~LHOME(Name~nda~mSS) ':
25. DATED~~SEDWA~sT~=.~:.~.(:;~26.~Un~c~h~db~M~i~=ex~m~r~w~d~a~hrep~dedt~ME?~1.Ye~ FXJ ZNo J ~1~ PJn~
D~. ~O O~ Y~R j Kemmerer, Wyoming
Driv,. S,~t L,k, Cit7, Ut.h
. .. :':?4, I HRtrh 13 ?~Q2 HBrch
, OR RESPi~Tb~y AR~O~T FASB[ ;:,LIS~ ONLy. bNE CAUSE ON ~CH LINE. ' ; Be~e~Onse~an
....... ; · PmoRm COUPLET O~
section 26~2,:22 otf 't'he Ui~h'~,'~d'b~i~l~nb~a~'i::tl:953 As Amended.
unaer authomy of
angle
County SALT L~E
¢~,~;~:DiRE,CTOR OF VITAL RECORDS
~ Registrar ~~
* 0 0 9 6 5 4 0 6 *
is to certif office. This certified copy is issued