HomeMy WebLinkAbout893221STATE OF WYOMING
COUNTY OF LINCOLN
AFFIDAVIT OF SURVIVORSHIP
B.OOK534 pR igAGE 0 3 5
RECEIVE/)
) LINOOLhl COUNTY CLERK
)ss. 893221
I, RICHARD A. HANDSAKER being of legal age and first duly sworn;:~le126~e~s and~s'ay~t- t-/
'. :':. ',,: ,~;, ~-. ,~ ,.' ~ ,,~.,...., ~, f;.,,,
as follows:
That Effie Mae Handsaker, the decedent mentioned in the attached certified copy of the
certificate of death, is the sm'ne person as E. Mae Handsaker named as one of the Parties in
that certain Warranty Deed dated August 21, 1981, executed by Leisure Valley, Inc. to
Michael B. Harris & Dianne H. Harris, husband and wife, and Richard A. Handsaker & E.
Mae Handsaker, husband and wife, recorded as Instrument Number 563869, on August 24,
1981, in Book 179PR, Page 734, 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:
Lot Sixty-Eight (68) in Star Valley Ranch Plat Fifteen (15) as platted and recorded
in the Official Records of Lincoln County, Wyoming.
RESERVING THEREFROM all rights, title, and interest in and to any and all
minerals and rights appertaining thereto.
Subject to all declarations of covenants, conditions, and restrictions of record.
That I am the same Richard A. Handsaker 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 E. Mae Handsaker, her previous estate in the property was terminated.
That the certified copy of the certificate of death indicates that Effie Mae Handsaker died on
January 18, 1983 in the City of Ogden, State of Utah.
Dated this L~'~ day of ~[)rtQ~,_..l~ ,2003.
RICHARD A. HANDSAKER
STATE OF UTAH )
) SS. .
COUNTY OF WEBER )
and sworn to beibre me by Richard A. Handsaker, this __
~ ,2003.
My Commission Expires:
L"}'l~day of
'NOT~-~ PUBLIC~ ' ~
29-0042-SS
LOCAL FILE NUMBER
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
~1,ATE OF UTAH - DEPARIMENrl' OF HEALTH
O36 ...
FIRST MIDDLE LAST Is~ RACE ~Nhlte, Black, Am. Indian, etc.)
I
EffZe Mae HANDSAKER ,Female White na~ry 18,19
WAS OECEOENT OF SPANISH ORIGIN? YES [] N~_[:~ H yes, IndlCale type:I OATE OF BIRTH (Month,Oay. Y~l y~r INOER 24 HOURS
...... I,~cemb~r ~z,~9~5 ,.57 ,,,.
Utah ~. USA o,~o,~ D' I-. 15 &.28-26-385~
Housewife h~. own home ],~char~ A~thu~. Hand,skor
859 F~anklin h~. ~ ~~ R~ch~r~ A.Hands~ke~-
ICOU.~ ~=ATEANDZIPCOOE 859 Franklin
c~ OR TOWN I I
.den 5-. Weber h~tah 84403 ,.Ogden,Utah 84403'
hosp,a~, nu,s~ng home o, othe~ i~smmion ~he,e d~m ~c~,,~. ~ ~n~'en~ ~C~ Da ZOWN ~COUN~
~ ~,~3939 Har~iso, Blvd. 0gden, Utah
I
STATE FILE NUMBER
OF DEATH {Month. Da
DERLYING CAUSE LAST.
)led lot registration by
'°~'b~ry ]9, ~983
PART II. OTHER SIGNIFICANT CONDITIONS--CONTRIBUTING TO DEATH, BUT NOT RELATED TO THE
NAME AND LOCATION OF CEMETERY OR CREMATORY
Eden Cemetery,: Eden, Utah ~._.2~,::...¢/'~'
PART I. DEATH WAS CAUSED BY: IMMEDI TE CAUSE: · (Enter only one cause per line lot A, B and C)
CONDITIONS IF ANY ~ ·
WHICH GAVE RISE TO DUE TO, OR AS A/CON~OUENCE OF/~ · j~ . I'tnter~al between ohset and death
TIlE IMMEDIATE CAUSE (Si ~ ~'--~(.~. ~ ~=_ llntervaI
(A). STATING THE UN- belween onset and death
DUE TO, OR AS A CONSEOUENCE OF
lC)., I
AUTOPSY I IF YES, were Rndingl
Inlerval between onset and death
!
. in delermining cause of death?
?ES I
3,..O YESO ,o []
PLACE OF INJURY {Specily home, farm, laciory, freeway,
street, oflice buildings, etc.)
MEDIATE CAUSE GIVEN INPART I.
Accident ~ Pending Invesligalion [] IDATE of Injury {Month. Day,Year) ITIME OF INJURY INJURY AT WORK?
Suicide[] Undetermined Ii Injured I ~ / ~,"~ . · ~ ~ ~ I (24 Hour Cl~k) ~S
Homicide O AccidenHy or Purposely O1,~..1~,6~,~ ~,~.O930 ' [~: L
;Distance from place ol inju~ lo
LOCATION DF INJURY~STRE~ AND NUMBER OR LOCATION AN~CI~ OR TOWN. ~usual ~esiden~ {Item lB) · done fel alcohol?
SHOULD BE 'ENTERED IN ITEM ~) . var, ~ssen~
This is to certify that this is a true copy of the certificateon filein this office. This certified copyis issued
under authority of Section 26-2-22 ot ~he Utah Code Annotated, 1953 As Amended.
~ Date Issued:
~ JAN 1 9 1983
~ County ~,]~ber //John e. Brockerl ·