HomeMy WebLinkAbout892542STATE OF WYOMING
COUNTY OF LINCOLN
RECEIVED
AFFIDAVIT - ESTATE BY ENTIRETIE~'tNOOLN cOUNty CLERK
8925q2'
)
) s~'BooKS3'1 PR'~AGE
)
175
Jerry T. Harmon, first duly sworn, upon oath, deposes and says:
1. JackB. Harmon and Lydia T. Harmon Were married to each other at ,x/o ¢i?.~_
on,~- 2_'~ ,- ~' and they lived together as husband and wife for°many years and
continuously until the death of Lydia T. Harmon
2. On August 16, 1988, Jack B. Harmon and Lydia T. Harmon conveyed by Warranty Deed
to Jack B. Harmon and Lydia T. Harmon, husband and wife, the real estate described as follows:
Lot Three (3) of Block One (1) of the Harmon Addition as platted and recorded in
the office of Lincoln County Clerk, Lincoln County, Wyoming.
The Warranty Deed was recorded in the office of the Lincoln County, Wyoming, Clerk and Recorder
in Book 264PR, Page 424, and thereafter Jack B. Harmon and Lydia T. Harmon, husband and wife,
became owners of the property as tenants by the by entireties.
3. Lydia T. Harmon died on ~.,z - ,29 - ,~__q . Attached is a copy of her official Death
Certificate certified to by the Vital Records Services, Division of Health and Medical Services,
Wyoming Department of Health and Social Services, the public authority with which the original
Death CertifiCate is of record according to law.
5. By reason of the death of Lydia T. Harmon, Jack B. Harmon became the owner of the
above-described real estate interests on ,~z - o~ ~ ~, $
of
SEAL
The f°regoCg instrument was acknoWledged before me by Jerry T. Harmon, this __~ day
, .~.~ , 2003. Witness my hand and official seal. My commission expires:
Notary Public
i Coilett Avenue:
(First. Middle. Last)
Hoomer Ida Derricott
MAILING ADDRESS OF. NFGRMAN~r :::~:!:i:~;i ~ ' ~ ~.[
Harmon /:Xfton, Wyoming 83110
21b. PLACE OF DISPOSITION ~name a/cemetmy,
:okeville, Cemetery
N~MBER
?o363
/ i624 E~st
if:
DEATH
6. StaTe,CE (~y ~ Stale
Ca~e Source
[ Jack B. Ha~on
LOCATION:, City
CokeviZi~
Larkin
SLC Uta~i 841}1
~, ~, ~na p~a, ~nd d~e io ~ m~(H ~1 man~ ~ smmd- ..: '"~':i'= .
A ~ ~GIST~ ~TIF ~ OF D~TH I ~ DATE FI~D (M~; ~ Yr.) ~ j'. ~': b; ~.~:?
Feb:ua~7 ~0~'~g003
~ O~TH. ~ NOT ENTER THE M~E ~ DY~. SUCH AS ~ :~* ~:~: ~ '
OF~.
33~.WASANAUTOPSY
PERFORMED?
~5. NON USER
Amended.
OF VITAL RECORDS
ill II Iil Illll Illtl II III IIIII Il Ill Illll IIIII IIIII "~
* 0 i 2 3 2 5 8 ~ ·
OF VITAL RECORDS AND STA'~I
HEALTH SECTION
_= USED TO MAKE CORRECTIONS
ig the appropriate box for birlh, death or fetal
lificate.
e~ enter the number(s) of the item(s) on the
on the original record.
the correct information as it should have be~n:~ 'i~t the 1 '
__ UNDER PENALTY OF PERJURY. This decl~rati6~:'rfl~, ;t'~e ..: :.:'
irtified lhe information in the medical and health .d~t~§ ~.~'tiO~i'of ~'"
so[ the ceH~ng phymc~an or medical examiner;~ S'; ~ ~:~: ·
the State Register. ::~;'.":~' :~'~:~;;~; ~..~.? =.; '/.: '
to the Office of Vital Reco~s and Sta{iSi~;2~'.~ i~'dh 1460 '
012, Salt Lake C[~. Utah :84114-~01~ ..; f acceptable for registration it will be f ed and be¢,m,~d: ~;~ ..
or g na record ' :~'(!;;'~:;'; ;'; .";:? ~ :~;~::}:"{ ":'~ .;';i ~. ~'::: ;~'.", ~ ':; ~'::"~;:.~ :J' ;' .'
plated within ~'n~ ~:~'O.f {h~a~i6' ;f bi~, death, or fetal death, there Is n° ie'~;fo~:i~ii~git.' :' -'
fee for a bi~h b~Hiflcat~' ~earbh and a sg.o0 f~ for a death or fetal death ceHifiCat~ ~'~ch, If '"
TOOMER
CIT~
, affidavit which includes one certified 'cbpy~otithe. ;:iL ii~. !/'~: :'
'RITTEN REQUEST FROM THIS oF~I~Ei:?!~??~ i' :.:,i
~IETAIN ALL MONIES PAID. ':
there is a $20.00 fee
E APPLICANT DOES N(
WITHIN 90 DAYS
3; DATE OF EVENT
EEB, 9, 2003
FATHER .....
TOOM~R
Sa. FACTS EXACTLY-AS STATED O
IDA DERRICOTT . ~
Bb. FACTS AS THEY SHOULD HAVE SEEN STATED ON THE
ORIGINAL RECORD i,~
MEDICAl.
(Print or Type)
OR Ida. SIGNATURE OF
KNOWLEDGE OF SUPPLEMENTAl,
J~C:DRMATION WHICH MODIFIES THE' .' i' 1 la, NAME OF r
I~i=ORMATION ORIGINALLY REPORTED~ '
D~CLARE UNDER PENALTY OF P~RJUR~ '
STRUE
= BEST OF MY
ilNAL RECORD
- " - 12b. DATE ACCEPTED
of the Utah
2003
C~'{ifi~i (~)py is issued
1953 As Amended.
Barry E. Nangle
: S DIRECTOR' OF VITAL RECORDS
*01232603*
March 11, 2003
r Valley
Sports/vtedici c
Kenneth F.B. Cobbs, M.D.
Star Valley OrthopedicS
P.O. Box 40
Atton, WY 83110
RE: ADDENDUM TO DEATH CERTIFICATE, LYDIA TOOMER HARMON.
Lydia Toomer Harmon was a patient of ours as Star Valley Orthopedics. She was admitted
to the hospital on January 9, 2003 following a hip fracture. She underwent open reduction,
internal fixation that is a surgical repair of her left hip. Post operatively she made slow and
intermittent progress on her medical and physical therapy recovery. Due to her preexisting
medical conditions the additional demands of healing of her left hip fracture were to great a
demand for her to negotiate. Due to poor progress in therapy and progressive weakening and
poor overall medical condition she was eventually transferred to LDS hospital in Salt Lake
City on January 23fa. Mrs. Harmon eventually died on February 9, 2003, one month
following her hip fracture.
As I review her certificate of death I note that aspiration pneumonia, thrombogenie,
thrombocytopenia purpuria and acute myocardial infarction are the listed causes of death.
These are noted to have occurred days and weeks respectively prior her demise. On the
second page of the certificate listed as other significant condition is the fracture to the left
hip. It is my opinion that the hip fracture sustained in the fall is what eventually led to Mrs.
Harmon's death. The physiologic cost and consequences of healing this hip fracture were
just too much for the patient to overcome. Additionally the lack of mobility due to the
fracture clearly would set up a situation in which aspiration pneumonia, myocardial
infarction, and thrombocyto~nia could arise. Please consider this information in regards to
the death of Lydia Toom/e(Harmon occurring on February 9, 2003.
Sincerely,~ //
Kenneth F.B. Cobbs, M.D.
Star Valley Orthopedics
KFC/ks
]
.......... P.O. Box/40 · A(ton, I, Vyontbtg 8311 ~:'-'i!!i!iii!!??::-e: 307-885-2100 · Fax: 307-885-5282. a' 'i :': ': .~o.com:i