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891223.
AFFIDAVIT
RECEIVED
LINCOLN COUNTy CLERK
03 OCT - 8 /t,,H 11: ~ 2
JEANNE WAGNER.
COUNTY OF /7~ i
I, Charles W. Walker, being first duly sworn on oath, depose and say:
That I am a citizen of the United States °fAmeriea over the age of 21 years, and a
resident of Littleton, County of Arapahoe, State of Colorado
That I was well and personally acquainted with Evelyn B. Walker in that certain Warranty
Deed dated April 9, 1993 and recorded April 19, 1993 in Book 327 P.R. at Page 333 as Filing
No. 763320 in the office of the Recorder of Lincoln County, Wyoming.
That I know of my own knowledge that Evelyn B. Walker in the said deed and
Evelyn Virgina Walker mentioned in the attached Certified Copy of Certificate of
Death was one and the same person.
This Affidavit is intended to terminate the joint tenancy (the life estate) of said Evelyn B_
Walker in the following described property:
Lot 33, Rees Subdivision, according to the official plat of record in the Office of County Clerk
Lincoln County, Wyoming.
Charles W. Walker
Subscribed and sworn to before me thisc,7 ¢ day of .~<~:/~-/~'* ~4/a_
W. Walk ~r. ~/~~
Not~ Public
Resi~ng in:
Co~ission e~kes:
My Commission Expires 6/13t20~6
,200_~, by Charles
~8k-:l 5lu/rOB'd i~[-I 9819-6£].-20E ~uedmo2 ell!l pue]-~0~ ~dgZ:iO iO-6Z-d]S
STATE OF COLORADO
CERTIFICATE OF DEATH
STATE FILE NUMBER
68O
1. OECEDENT'S NAME First Middle. Lasll 2. SEX 3. DATE OF OEATH (Month, Day, Year)
Ev. elyn Virginia WALKER I Fa. September 24, 1997
4. SOCIAL SECURITY I Sa. AGE - Last~ 5b. UNDER t YEAR 1 5<:. UNDER I DAY 6. DATE OF BIRTH T. BIRTHPLACE (City and State or Foreign
NUMBER [ Birthday (Years~ ]Mos : Days I H~s i Mine (Month, Day, Yea() Counlry)
218-14-0199 74 I March 29, 1923 Baltimore, Maryland
8 WAS DECEDENT EVER IN ga. PLACE OF DEATH (Check only one) '
U.S. ARM?D F~..~CES? HOSPITAL: · ~ OTHER
O Yes [Z~,~qo O InpatientO ER/OutDatienl ri DOA i i-1 Nursing Home J~.~Re~siesidence O Olher (Spec#y)
9b. PAClLlTY NAME [,, no, institu,ion, gives,reelandnumbor, I 9c. CITY. TOWN. OR LOCAT,ON OF DEATH I 9d. COUNTY OF DEATH
6074 S. Columbine Way Littleton Arapahoe
lOs. OECEDEN'FS USUAL OCCUPATION ~ '10b. KIND OF BUSINESS/INDUSTRY ] t t. MARITAL STATUS - Married,
(Give kind gl work done during most gl working life. I Never Married. Widowed, 12. SPOUSE (11 wile, give maiden name)
Do not use retired.) Divorced (Specily)
Homemaker Own Home Married Charles W. Walker
13a. RES,DENCE-STATEI ,3b COUNTY I 13c. CITY. TOWN.OR LOCATION 13d. STREET AND NUMBER
ColoradoIArapah°e ] Ltttleton 6074'So. Columbine Way
13e. II'~SIDEI 13f. ZIP CODE 14. WAS DECEDENTOF HISPANIC ORIGIN? tS. RACE: Americanl,dian 16. OECEOENT'SEOUCATON(Specifyonlyhi~hest
CITY ] ] (Speciiy NJ) or Yea - II yea. specily Cuban, Black, White, otc. (Specily) grade co~pteted) Elemen ar,/or second=r`/
I
% I8°1:11 I ' White I
m;~1~17. PATHER-NAME (First. Middle, test) 18. MOTHER-NAME (First. Mlddte. Lest (Maiden Name)) ] 19. INFORMANT-NAMEandrelallonshiplo deceased.
~X~ O;orge Wheat I Mabel Kauffmann I Charles W. Walker ( Husband )
~'20a.. M~T~O OF DISPOSITION ] 2Ob. PLACE OF DISPOSITION (Name gl cemetery, cremato~/, orl 2oc. LOCATION - City or Town, S ate
~DDonation OOther(Specily)__ I Cha el Hill Cemeter I L
~ ) I P Y I tttleton, Colorado
I 'lL S?T ".'OFPU. LD,R' CTORORP R ONAC .O^ SUC. I ,b..AM£ANOADORE ,OF.C,L,TY:
~, /~x/. /.~,~ ~' IDrinkwine FamilY Mortuary 999 W. Littleton
~~-f'~/~~/~ JLittleton, Colorado ziP: 80120
· MI M n,h O.y q/ --(/ .OH. I '(Y .... .o, ·
7:40 k I September .24, 1997 7:40 AM I Yes
TO BE COMPLETED ONLY BY CERTIFYING PHYSICIAN
26. To the Deal ot my knowl~;Ige, death occurred al Ihs lime, dale end piece, end due Io
the cause(s) endmenp~r as eta. Led.
28. DATE SIGNED (Month. Day, Ye~
September 24, 1997
TO BE COMPLETED BY CORONER
27. Onthebeslsolexamlnalionand/orlnvesllgaUon, lnmyoplnlondea hoOCH;reda he
time, dale and place, and due ID the cause(e} and manner ae etaled~
Signature
29.' DATE SIGNED (Month, Day, Year)
30 NAME. TITLE AND MAILING ADDRESS OF CERTIFIER/CORONER [Type/Prinl)
Jennifer Arnold M.D. 7447 East Berry Ave. #150 Englewood, Colorado mP: 80111
3`l. NAME OF ATTEND NG PHYSIC AN IF OTHER THAN CERTIFIER (Type/Print)
(Month, Day. Year) WORK?
alural O Pending
Invesligallon M O Yes O No
[~ Accidenl
[3 Suicide O Undetermined
Manner 3.3a. PLACE OF INJURY-Al home, farm, street, lictor'/, office 331. LOCATION (Slraat ~nd Number or Rural Route Number, City, County. SI~Ie)
building, sic. (Spec#y)
~ Homicide
34. IMMEDIATE CAUSE IENTERONLYONE CAUSE PER LINE FOR ~e). Cb). AND ~c).l Do not entel' mode ot dying (e.g. Cardiac or Resplralbry A~'resl) alone.
PART
CONDITIONS DUE TO OR AS A C'ONSEQUENCE pF
IF AJ%'Y WHICH
GAVE RISE TO
lb)
IMMEDIATE CAUSE
STATING THE DUE TO OR AS A CONSEQUENCE OF
UNDERLYING CAUSE
LAST (c) (c)
PART OTHER SIGNIFICANT CONDITIONS - Condlllons contributing to death but not related to cause In
II PART {e.g~ alcohol abuse, obeslly, smoker),
~-T*ATE OF COLO~ApO, TRI-COUNTY HEALTH DEPARTMENT - United States of America
! hereb~ cert~f~ this document is a true and correct cop~ of the record In
my custody. Issued this 26~h! day of September 1997
This is not valid unless prepared by blue basketweave paper and
impressed with the raised seal of Itl-County Health Department.
PI ( LAJ~ if any ~erson alters, uses. atte~':' use or furnishes to
a~.J,~,.~-*,er deceptive use any vital statistics i[:::i,i:!$!::!': :ate.
Inle~albetween onset
and death
Inle~albetweeo onset
and death
Inlen~al belween onset
and dealh
35. AUTOPSY J 36, IF YES were findings considered
(Yes or No)Iin determining cause OI death?
I
.No I
Chris J. Wi:fa'hr, M.P.H.~ Ph.D.,Registrar
Lois L. Sc : :' :Jputy'Reg~s:rar