HomeMy WebLinkAbout894209~00K
STATE NEW YORK }
} ss
COUNY OF ~,a,r~,o~,n
RECEIVED
',LINCOLN COUNTY CLERK
8;9 [~A~F~gVIT OF SURVIVORSHIP
03 0CT - 73: S 9
SUBJECT cONcERNING: The death of Wilma Sue Ingram Thompson hi ~n~[~.~gnO"~i,?{ "['
Thayne, Lincoln County, Wyoming, consisting of one lot, described as L~T/]~'~
(311~4) in Star Valley Ranch Plat Twenty-one (21), as platted and recorded in the ~fficial
records of Lincoln County, State of Wyoming Registry of Deeds. Title Reference:
Quitclaim Deed dated May 28, 1994 and recorded on August 2, 1994 in Book 355PR,
Page 105, #787498
BOBBY JACK THOMPSON being of lawful age and tn'st duly sworn on oath
according to law, deposes and says:
o
That I' am the surviving husband of Wilma Sue Ingram Thompson.
That by virtue of the subject Quick Claim Deed, Wilma Sue Thompson,
and I (joint owners of the subject property), granted one-half ownership in
the subject property to Jay W Brown and Patricia Anne Ingram Brown.
The affiant certifies that Wilma Sue Thompson, a/k/a Wilma Sue Ingram
Thompson, died in the City of Detroit, Wayne County, Michigan, on
December 16, 1998, and a copy of the official Certificate of Death of said
decedent, certified to by Gall H. Patton, Registrar, Vital Records, Detroit
Department of Health, is hereto attached and hereby made a part of this
affidavit.
That this Affidavit is made for the purpose of making a matter of record
the termination of the previous estate in said property of Wilma Sue
Ingram ThompsOn and establishing the survivorship to Bobby Jack
Thompson.
Dated the ~ day of September, 2003
Bobby(~~pson
STATE NEW YORK }
) ss
COUNY OF ~'~
The foregoing instrument was acknowledged before me by Bobby Jack Thompson this
['~ day on September, 2003
WimesS my hand and official seal
My Commission expires
LAURA M. HARRIS
NOTARY PUBUC State of New York
No. 4-'977839
Qualified in Ono.dage County
LF ~ STATE OF M CHIGAN_____._ 6 5 2i,:..:
- ' ' ' '- ' ' ' ' DEPARTMENTOFCOMMUNITYHE:AITH
STATE FILE
cf ".O10325.. C["T,F,C^TE OF DEAT.1.4'74258
Wilma Sue Thompson Female ~ec~mber 1~::; '199a
4a AGE- Last B,rthdayI 4b UNDER I YEAR 4c UNDER ~ DAY I§ DATE OF BIRTH (Afonth. Day. Year)
65 J ~ , JUne '25, 1933 ne
7a LOCATION OF DEATH (Ente, place officially I)ronounced dead.,n 7a. 7b. 7c.) 7b IF HOSP OR INST Inoal,ent. 7c:: ~;ll~'. VILLAGE, 0~'~'0WNSHIP
HOSPITAL OR OTHER· INSTITUTION ~ Name (11 not ,n e, thef. g~ye ~feet and number) ~ Op /[mer Room. DCA (Sp~ffy) :De ~ ~
:Harper Hospital Inpatient m tro
8 SOCIAL SECURITY NUMBER '
~a. uSUAL OCCUPATION (G~ve kind of work done dunnE most of 96 KND OF BUSINESS OR INOUSTR~'
561-44-5627 I Hjmemaker ' I Own Home .:.
lOp. ZIP COOE ~11 ~IRTHPLAC[ (C,ty:and ~12 MARITAL STATUS- Ma,r,~ 1~ SURVIVING SPO~S[ : ' Ii,
48357 '
15. ANCESTRy- Mexi~n, Pue~o R~n. OuCh. Central or ~uth
~8, FATHER S NAME (F*rSt. M~ddle.
19 MOIHER'S NAME (F,rst. M~ddle. Surname ~fote hrst matt,eD).:
Alfred H. Inqram Catherine Foote
L INFORMANT'S NAME {Tyler ~t) 20b~ MAILING ~DORESS (~t~ee~ a~d Number or Rural Route Mumbo City ~ W~ge. State;.~lP C~ -. :..
Bobby Jack ThOmpson 2100 Adda~een Rd, H~gh~and, M[. 48357
21.Removal.METHOD OonationOF DISPO~lTotherON(~pecify)-Burial; Ciemahon.. 22a. orPLAC[ot~efOFplace)DISPOSITION (~ame of Cemete~.Crematory ~22b. LOCATION ~Cdy o~ Vdlage. Stat~
Burial Welch Church Cemetery j" { N:'ei:;gon::; :"~:bW Yor~:
23 SIGNATURE OF FUNERAL SERVI~[ LICENSEE 24 UCENSE NUMBER
25 NAME AND ADDRESS OF FACIUTY ~::" ,i ....
~ ....... ~ Potere.Modet'z.gune'nal ~°me, Inc.
19 339 Walnut. Blvd.,. Roc. hes%er:.'~ MI 48307
arresL sh~k: or hea~ lamlu~e. List only one (ause on each hne
resulIiOg m ~ealh): ODE TO ~O~ ASA CONSEQUENCE OF): : :", '::~:~ .....
Sequenl,ally m,sl,,cond,l,ons, m ,, ', ~' DuE TO ~OR AS:A:CONSEQUENCE 0F)
thai ,ri,hated evenls ."~ ~ :: ' DUE TO'(O~:,AS A CONSEQUENCE 0F) ' '
PART II Othe~ s~gmflcanl tonal*boris co~irmbut[~g t~ death bul not ~esultmg m ihe u'~rlymg cause g~ven ~ Pa~ I
Home. Hospdal. Ambulance) ~Soectfy)' ": I EXAMINER?R£FERRED
30a To the best of my knbwledge' dea h occurred aJ,4~e bme ~a e aha place and due
toth~ causes) ~t~ted '~ ~ f~'m '" :' I'
~ 30~ OATE SIGNED ~. O~y:Yr):. ]0~ TME CE DEATH ' ' ' :::'
30d NAME OF ATTENDING PHYSICIAN IF OTHER THAN .CERTIFIER (Fype or Print)
OF DEATH? ~Y~ Or/90)
at th~ hme..date and place and due:tO t~e ~a~%e(s) a~ld n~a~nef ~taled[
~,.~ 3ih DATE SIGNEO (Mo ' Day': Yr ) NUMBER
~.x, 310 PRONOUNCED DEAD (Mo rtl ]Ie TIME OF DEATH
ON
32a NAME ANO'ADORESS:OF PERSON WHO COMPLETED CAUSE OF DEATH ·(ITEM 26) (Type o~ Print):..; .:
32b LICENSE NUMBER
ACC. SuiCIDE. HOM. "'
TY (MO ~' Da~' Yr ) 33c: TIME 0£' N JURY 33d DESCRIBE HOW INJURY OCCURRED
:'.~ :. M
33e(Spec*fyINJURY Yes or No) 33f PLACE OF INJURY'~ off*teAt nome.DudOsng~arm e~cSlree~soecffy)'"fact° y. 33g lOCATION- Sl~eel o~ R F O No :'Cd~. Wllage or Twp
THIS CERTiRIES THAT THE .ABOVE IS A TRUE COPY OF FACyS RECORDED ON THI'S REcoF~D :::: :::' ' ::.: -'-?'
O~ THE PEARSON NAMED'i~iEREON, AS FILED AT THE DETROIT DEPARTMENT OI~ :HEALTH
v,,.,,,. .. :: -
DATED :'~'!': ..... :-'s, - ............ . DETROIT DEPARTMENT OF HEAl:TH :.!!:
~ 1151 TAYLOR
= DETROIT, MI 48202 ' - ' "~ --
'" :' '~ ':' ;':':: Y' ] ~: ;J .......... : :~ :::-~ :;"' ..... ...... :;':;'~::::::i"~::~i~::i.,~!: :::::: '-
..... - Department of Health ::~?.
Vital Records .:~