HomeMy WebLinkAbout904803Affidavit of Survivorship
(-, 0397
I, Walter E. Dybowski, being of lawful aoe and duly sworn according to
law, upon my oath, depose and state:
That under the date of July 9, 1975, for vak~able consideration, Paul F.
Ellis and Lillie Ellis, husband and wife, by deed of that date, which deed was du~y
filed of record in the Office of the Lincoln County Clerk, on July 10, 1975, in Book
119 of Photostatic Records on Page 532, conveyed to Walter E. Dybowski and
Phyllis L. Dybowski, husband and wife, as tenarlt.,; by the entireties, the following
described property to-wit:
Lot 11 of Block 33 of the First Addition to ~he Town of Kemmerer,
Lincoln County, Wyoming
That by a subsequent conveyance that was filed of record in the Office of
the Lincoln County Clerk, on February 20, 1990. in Book 283 of Photostatic
Records on Page 258, Walter F. Dybowski and Toni Dybowski, husband and
wife, conveyed to Walter E. Dybowski and Phyllis L. Dybowski, husband and
wife, as tenants by the entireties, a portion.of the ~ame said Lot.
That by reason of said conveyances ~roresaid, the said Walter E.
Dybowski and Phyllis L. Dybowski became the owners of Lot 11 of Block 33 of
the First Addition to the Town of Kemmerer, an~ title thereto vested in them
continuously from the date of conveyance descrih~d in said deeds to the date of
death of Phyllis L. Dybowski on the 31~t day of Au~just, 2000. That by reason of
and upon the death of Phyllis L. DyboWski, title to the above described real
property vested absolutely in Walter E. Dybowski.
Affiant avers and certifies that Phyllis L. D~'l)owski is the identical party
named with Walter E. Dybowski in the aforem~;~tioned deeds whose death
terminated her interest, title and estate in said real property; and Affiant attaches
hereto and makes a part of this affidavit, a copy of tl~e Official Ce=rtificate of Death
of said decedent, duly certified by the public aulhority in which said death
certificate is a matter of record.
Dated this ,:,q/,-¢ day of/k//~¢7'~)~,4", 2004
RECEIVED 11/24/2004 at 12:12 PM
RECEIVING # 904803
BOOK: 573 PAGE: 397
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
State of ~)~/'_,,~,¢z,,~/~/' )
County of L//~_~/~ )
Walter~bowski
Subscribed and sworn to before me, a notary public in and for said County
and State, by Walter E. Dybowski, this ~ day of _ '~2z..'¢:'~,/.[,,~[-, 2004.
WITNESS my hand and official seal.
LIZABETH M. FAGN^NT - Nutary Public'~
County ~ ~ State of ~
Llnco/r~ ~ Wyoming H
IL4y Commission Expires Jan. 7, ~',~.~/
Notary tSubli~;r..~
My Commission Expires: /"- ~ - 0._4"-
P~RMAf~NT
BL,~CK
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INSTRUCTIONS
SEE
HANOBOOK
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DEPARTMENT OF ttF^LTH
· OC~._E.U~.~R [020 CERTIFICATE OF ;3£ATH
1. D~CEOENT-NAME FIFl~r MIO~L.E LAbT
Sou~ Lincoln Medical Center
S~ ~ ~ (~ ~ ~ U.~A., ~
Utah
No
Wyoming Lincoin
Ke~erer
I ~n, ~, ~ ~, E~)
Yes I ~ ~" O t~")
Frank Lamborn
~alter E. Dybowsk~
~O ~ESS 8TRE~ ~ RF.D,
403 ?e~ S~
0398
~TATE FILE NUMBE~
z ,~x I: O*TE O~ ~^T. (~. ~.),. ~.)
Phyllis Dyb~a..'~;ki FemaleI August 31, 2000
520-16-~119 .... October ~ 1921
7L ~E ~ D~ (~ ~ ~1
.- j,~t.irY TOWN OR LOCATION OFDEATH ITd. COUNTY OF DEATH
I
Kemmerer J Lincoln
HAR.RED. NEVER MA.R/:UED. ~L' L,[JNVNING SPOUSE (M IMM, g~e ~ hims)
WIDOWED, DiVC~qCED
/
Married Walter E. Dyb0~sk±
Operator el~phone
13C. CITy. TOWN OR LOCATION I t3~ STREET AND NUIJaER
403 ?earl Street
1:: NACE-American Indian.
I(~,c~h,)
p d ~A. )~HER'S NAME
/ Ethel Bellman
Husband
CITY OR TOWh STATE ZJP
Kemmerer, Wyoming 83101
2~. BudlL Cmmatian, Remov~12Ob.[:~TE (M~, ~, wj
Sate. ~(~y}
I
JCremation/BuriallSept. 2, 2000
VR 2-89
8/97 15M
20=. C~METERY OR CFIEMATOi~ ,' N^ME 120~. LOCATION C~ OR T~N
Salt Lake M;~]~;oleum I Salt Lake City, Utah
~ ~~ 429 ~randall F~eral Home 28 I Ke~erer, Wyo~ng
2~. PRONOUNCED D~D {~. ~, WJ
24. ~ ~ A~ ~ CEdaR [~Y~ ~ C~O~R)¢~ ¢ ~j
Christopher Krellr ~ 71I'On x Kerra~rer, W omin' 83101
I ,~, ' d~ ==~.-~// ISeptember 2, 2000 '
~ I~ ~ ~E TO (~ ~ A ~N~QUENCE OF):
~E (~ ~ ~ ~E TO (~ ~ A ~ENCE O~:
MANNER OF DEATH 304. DAI~ OF II, UORy 3ob. TI&~ (~
(Monm. ~W. YM~) INJURY
_~ ~ _~_ C~uk~ mx be (MIiM ~ Mc~ ISpec~y )
27. AUTOPSY/,~aec#yJ28. WAS CASE REFERRED TO CORONER
I No / No
j.,~^ I~URY AT WORK? J3Od. DESCRIBE HOW I~JLI~Y OCCURRED
30L LOC^TIC~ (Sl~l m~l NumbM or Rur,u ~ Number, C~y m Town. Stale)