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'ii00K_ a4 PR PAOE3- 6 8
STATE OF WYOMING
COUNTY OF LINCOLN
RECEIVED
LINCOL. I'.,.! COUNTY OLERK
I, Roger D. Toomer, being first duly sworn on oath, depose and say:
That I am a citizen of the United States of America over the age of 21 years, and a
resident of Montpelier, Idaho
That I was well and personally acquainted with Nancy L. Toomer in that certain WalTanty
Deed dated March 14, 1989, Book 277 P.R. at Page 201 in the office of the Recorder of Lincoln
County, Wyoming
That I lmow of my own knowledge that Nancy L. Toomer in the Said deed and
Nancy Lee Bentsen Toomer mentioned in the attached Certified Copy of Certificate of Death
was one and the same person.
i
This Affidavit is intended to terminate the joint tenancy (the life estate) of Nancy L.
Toomer in the following described prope~:
J
see Attached Exhibit "A"
Subscribed and sworn to before lile this & day of August, 2003.
State of Wy~lng-No~ P~ ~
Coun~ of U~ , ~
Residing in:~ ~~ ~'V~ ~
Conm~ission expires: ~.~ --
Notary Public (.,,/ - -
.369
EXHIBIT "A"
Lot 809 Lakeview Estates 3gd Filing, according to that plat filed July
30, 2003, in the Office of the Lincoln County Clerk as Plat No. 250-D.
HEALT
COOPERATIVE CENTER FOR 450 W. STATE ST.
HEALTH STATISTICS - VITAL BOISE, IDAHO 83720
CERTIFICATE OF DEATH
DATE FILED: NOVEMBER 25, 1991 STATE FILE NUMBER: 91'06433
DECEDENT: NANCY LEE BENTSEN TOOMER
DATE OF DEATH: NOV. 19, 1991
DATE'OF BIRTH: MAY 03, -1949
AGE: 42 YEARS SEX: FEMALE
MARITAL STATUS: MARRIED
PLACE OF DEATH: MONTPELIER, IDAHO
PLACE OF BIRTH: IDAHO
VETERAN? NO
SURVIVING SPOUSE: ROGER TOOMER
SOCIAL SECURITY NUMBER: 518-68-7782 RESIDENCE: MONTPELIER, IDAHO
FATHER: A. J. BENTSEN
FATHER'S BIRTHPLACE: IDAHO
MOTHER (MAIDEN): PAULINE BARKDULL
MOTHER'S' BIRTHPLACE: IDAHO
MORTUARY: MATTHEWS MORTUARY, INC.
MORTICIAN: LEONARD H. MATTHEWS
CERTIFYING PHYSICIAN: LARRY D. BOMSTA, MD
1. CAUSE OF DEATH, UNDERLYING CAUSE LAST:
CARDIAC ARREST
PROBABLE PULMONARY EMBOLISM
METASTATIC BREAST CANCER
MONTPELIER, IDAHO
DISPOSITION: BURIAL
AUTOPSY: NO
INTERVAL
5 MINUTES
· 15 MINUTES
2. OTHER CONDITIONS CONTRIBUTING TO DEATH BUT UNRELATED TO ABOVE. CAUSES:
NONE LISTED
DATE ISSUED: DECEMBER 02, 1991
This ts to cer~O~y that this is a true and correct reproduction or abstract of the official record
fled with the Idaho Department of Health & Welfare, Boise, Idaho.
RICHARD W. BLAIR, State Registrar
DO NOT ACCEPT UNLESS ON SECURITY PAPER WITH EMBOSSED SEAL OF IDAHO
DEPT. OF HEALTH & WELFARE CLEARLY AFFIXED.
Section 39-273, Idaho Code