HomeMy WebLinkAbout906626· , 04.. 8
Affidavit of Survivorship
I, Edward L. Nelson, being of lawful age and duly sworn according to law,
upon my oath, depose and state:
That under the date of July 25, 1978, for valuable consideration, Edd R.
Moore and Allie P. Moore, husband and wife, by deed of that date, which deed
was duly filed of record in the Office of the Lincoln County Clerk, on July 19,
1985, in Book 228 of Photostatic Records on Page 418 conveyed to E. A.
Nelson, Burdean nelson and Edward L. Nelson, as joint tenants with full rights of
survivorship, the following described property to-wit:
Lot 132, Star Valley Ranch Plat 6, Linco n County, Wyoming,
together with improvements located thereon
That by reason of said conveyance aforesaid, the said E. A. Nelson,
Burdean Nelson and Edward L. Nelson became the owners of said real property,
and title thereto vested in them continuously from the date of conveyance
described in said deed to the date of death of Burdean Nelson on the 19th day of
March, 1998 and the date of death of E.A. Nelson on the 4th day of September,
2004. That by reason of and upon the deaths of Burdean Nelson and E.A.
Nelson, title to the above described real property vested absolutely in Edward L.
Nelson.
Affiant avers and certifies that Burdean Nelson and E.A. Nelson, also
known as Edwin August Nelson, are the identical parties named with Edward L.
Nelson in the aforementioned deed whose death terminated their interest, title
and estate in said real property; and Affiant attaches hereto and makes a part of
this affidavit, copies of the Official Certificates of Death of said decedents, duly
certified by the public authority in which said death certificates are a matter of
record.
Dated this __~'"~N day o~¢~,r-¢,~ , 200~___.
RECEIVED 2/22~2005 at 2:28 PM
RECEIVING # 906626
BOOK: 579 PAGE: 408
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
State of u~] )
)SS.
County of WAS,Zt,~;'~N )
Edward L. Nelson
Subscribed and sworn to before me, a notary public in and for said County
and State, by Edward L. Nelson, this 5th day of a~iu~'~¥ ,200 5.
WITNESS my hand and official seal.
My Commission EXpires:__
~~Nota~ ~ublic
.OT^.VPu .,c I
KAYTEE POSTMA !
SUITE 202I
ST. ~ORGE UT ~770 j
~Y coaa ~P ~-~1
... ..... .~ CERTIFICATE OF DEATH
.... ,COAL F.LE NOMBER ~.l ? - / 6 & ST^TE PILE .U.BEP
Aug 15, 1912 [ · 85 :: I ...... I .... I .... I ........ I East St. Louis, IL 520-22-8561
'S{~ georKe · Washington; Edwin A. Nelson
77S Diagonal ~1 , St. Ceorge Washington ~ UT
iNSIDE Cl~ 13L ZiP CODE 14, WAS DECEDENT OF HISPANIC OR GIN? ~ 1 Yes ~ 2 NO 15 RACE - Bla~, Wh~m ~, Indian 16 EDUCAT ON
[~THER'$ N~ME (First. ~ddle. ~st) 18. MA~DEN HAME OF MOTHER (First, Middle.
ch~lg~ ~ohn~on -t' '. I Ella Jensen '
'g~&~'X. Ne[so~ '(HusbA~~) ?76'~1A[o~1 ~1 St. Geo~Ee, UT 84770
SIG~AT~RE OF f~ERAL ~RV[CE UCENSEE ' 23. LICENSEE NUMBER 24. FUNER~ HOME N~e. ~,*ss ~d ~cen,*
25. OATEpECEASEDWAS~ST 26.1 holcem/i~dbym~,~e~am~r w~de~ e~ME? ~1 ~., ~ ~ 288 West St. GeorEe
~ 1. C~RTI~ING PHYSICIAN .TS t~e b~t of my knowledge, death occurred at the lima, date. and place, and ~ue lo the cause(s) and manner as staled.
' :d~te, place, and due to the causa(s) and manner as stated. - '
2~b. SG~TUREfiNDTT~OFCERTFER ~ ' ' /~ /~ ~ 27c LCENSENUMBER 27d OAT .... ~
~M~ ~O ~DORESS OF PERSON WHO CERTIFIED THE GAUSE OF D~ (~ 3U
3~p~T EN~RT~EDISEASE~ I~UR[~S OR COMPUCATIONS THAT CAUSED THE DEATH DO NOT ENTER THE MODE OF DYING SUCHA~4~n~p
~R RE~PI~TORY A~REST SHOCK OR H~RT FAILURE LIS~ ONLY ONE CAUSE ON ~CH L NE .......
'AR~ Il. ~he, Significant Co~i, ..... d"u"ng ,o dean bu, no( ~2 N YOUR DP N ON TOBACCO USE BY THE DECEDENT 33m WA" A"
: ' . ' . 35e. LOCATION {S~f ~ ~ ~euM ~ ~ or o~, ~nfy a~ s a · 35 mom veh c e ~ent sp~i~ ~ dec~ent w~
5[:""~;'~ ~;-- Pen~. 3~. DESCRiB~ HOW INJURY OCCURRED ..... q ............ h~ .... d nnu~ NATURE OF N JURY SHOULD BE ENTERED N TEM
County
this is a true copy of the certificate on file in this office. This certified copy is issued
~ction 26-2-22 of the Utah Code Annotated, 1953 As Amended.
2005 '
~~2~.~ Barry E Nangle '
DIRECTOR OF VITAL RECORDS
*01136759,
County
~ DEPARTMENT OF HEALTH 0 4 'i!01 '
~1[ OF DEATH '~ .... -
STATE FILE NUMBER
I NAME OF DECEDENT ' F RST ~!~ X MI~,~E~, ;~,.};; (': ~ [.&ST ' 2. SEX 3a. DATE OF DEATH fmc.. Day, YO 3b,TIME OF D~TH
:, ~.DATEO~BIRTHf~..~Z,¢¢.)~ ';~:,'% :~' ¢~.~'~'~y¢ IFUNDERtY~ I~UNDER24HRS 6. BIRTHPLACE(C/Iy&SIale°rForeiBnCoun~) 7SOCALSECURTYNUMBER
. ,- : , , ', .;..~ . ~ ~,; ;; ~;&;'~/~ 2: Moqths Days H~rs Minules
~ 8e, P~C~ ~osp[T~~ ~1~~ ~RTH,~OgATIgN~: 8b. NAME OF HOSPITAL NURSNGHOMEOR~THERFACL~
, . OF D~FH '~ ~ I' ~e~t ;" ;'%/¢~ ?~'~ ¢~:~,; ~ :5'Nu~, H~me ~6 Residence 'an-' ( / eu s~e a fac#dy, g~e sEeel addres~ of
Ii: Cl~ YbWN OR ~OC~T O¢:~¢ O~ ~";' :; ¢ ?l~ ' ¢~UNTY OF D~TH 9 SURVVNGSPOUSE(Iwilegvema~annane)
P~C~D[~T~:¢' lO WASDEaEDENT' 11 ~TgT~?~;~*~t.~/~: ~12a BECEDENT'SUSU~OCCUPAT~N Gvekndo wokdone112b KIND OF BUS NES
,,<;~>;,l~,}; I~,I~IDECITYi '13f.~p'c0pE:;:: ~j'~A~"0E~ED~DFHISP~NI~ORIGIN? ~I. Yes ~2. No 5 ~CE-Black, White.~.
P~TS :~ 1~. FATHER'S ~E (Fi~t, ~'d¢¢:¢¢~):~/2;¢~ ~ ~:?':%' ~,; ' 18. MALDEN N~E OF MOTHER (Fir~[. M,ddla,
~:.. ~;'" ,,-' .;~}~?~v;~,~/}~¢~}%~,~}?~?~;?::-..:, ~', Laura Jen~en
': ~?' :.~; g4~¢' ~gSO~ · ;*'k ~; '; ;;', ¢ '? ;Zcz ~ ~ ~, / ;¢" 'e:;~' .
~FORU~f. :~i:~/;{~ "-~ .. ~ '- '<;;G~¢;.~;;;R~¢}(G}<:';¢.;' :,' :.' . .
' : ~ward L~e ~LSON~r~¢;,}~%~<::~f';'P,~:~. 7¢~.~.{ ,- :776 Diagonal ~24 St. ~orge, O~ah 84770
( ~"$)GNATU~ 0F FUNE~' SE~VIq~I~NSE~: ~¢¢~¢¢ :.~ ~; }. . ~3: LICENSEE NUMBER [ 24. FUNE~ HOME (Name and address}
~{ ': "~.% ~">1.',:";.',:{~:~:[~:~;;'~'~.;'':'' ' ..~ ~*~ ~. Is~. ~o=~., o~.~ ,~o ..
27~.'Q~[IER.,"::;~)~ ;',~;,j~F,~!, :. ' ' .
:.-: '~ i ~ ~'CERTIFYING PHYSICIANPTO.~ b¢~t'~f ~'~¢~ ~a h oc~d a the time da · ~nd ~a~ and due o he ~use s ~nd manner as s~ ed
CERTIFIER ~.~~mi~'~e~isofe~m~a¢o~en~or~ves~aflon ~myopin~n, death ~u~ed al ~e [me dae pa~anddue~e
27b:'$ ~? ~:'' - ' ' 27cL CENSE NUMBER
(~.R~EiST~'SSGNATUR/: : ~':{~¢::2'~'~, .( 3Ca DATEREGST~RNOTFEDOFD~TH 30D DATEFLEDf~ Day
REGIS~ ",' ' ;~ ? :;~:S; ,,, - ,.: V :~ ' ' ¢;~ > '' -, -, ' , . ; - ' ' f~., ~r, Y,J ..... ,'
3~, ~T~ ENTER THE OI~EAS~S ;IN~E~ ~R C~ ~TIONS T~ ~AUSE~ THE ~EATH DO NOT ENTER THE MODE O~ DYING SUCH AS CARD AC Approxim~le
OR ~BI~TORY'~E~T,~'~,]~ H~.[~i~ LI~T ONL~ ONE CAUSE ON ~CH UNE Baleen Onse
death ~8T. ,~ < < - ,:<,,,.~, ..~ ~ - ~:, ~ .~-<,,,.¢ ¢~, ,' ."
PAR~ [I; ~ar $lgn~i~nt Condi[o~ ~h~i~qg t~'d~ :-~ IN'YOU~ OPINION TOBACCO USE BY THE DECEDENT 33~ w~ ~
~*,,c~'n= bdt~l mS~ a~ m me u~ed~h~ ~u~ gj9~ff ~ ~'¥ j y~j)::;..¢; >... ~... :'; . A~OPSY 33b. W~ AUTOPSY
............. · .,.~¢~ .-~, .... ~....~.ow. 0'.'" ~..o 0''~''
~-M~NEROFD~ ' '.;;>~%;C ~5~¢~¢E:~}~(~; Da~, ~¢.) 35b TIMEOF NJURY 35c.)NJURYATWORK? 35d P~CEOF NJURY-A he~e ¢~ ~[ee
~3 Su' ~e,?'' ~H~m '~?' 3~[~AI9~2~$~r~'~mWenu~r'=i~y ....... a,yandsae) '35 ..... h ..... dent, spac~ de~d
. ~ ~ ~ ' . ~ ~{~;;~'2J';~;~}X ~ 0nye passengero peoes~n
file in this office. This certified copy is issued
1953 As Amended.
! E. Nangle
3TOR OF VITAL RECORDS
.016],9394.