HomeMy WebLinkAbout909634The State of Wyoming )
: ss.
County of Sweetwater )
~LFFIDAVIT FOR DISTRIBUTION WITHOUT PROBATE
RECEIVED 6/30/2005 at 2:30 PM
RECEIVING # 909634
BOOK: 589 PAGE: 855
JEANNE WAG N EF'.
LINCOI. N (;OUNTY CLERK, KEr',IMERER, WY
COMES NOW Robin Smith, of legal age, and after having been
duly sworn upon her oath, deposes and says as follows:
1. Albert B. Atwood, also known as Albert Bud Atwood and
Albert Atwood, died on February 24, 2005 at Bellevue, King County,
Washington. At the time of his death he was 65 years of age, was
a resident of the State of Wyoming and resided at 16 Gomer Street,
Keramerer, Lincoln County, Wyoming. Affiant is the daughter of the
decedent and makes this Affidavit For Distribution Without Probate
by and on behalf of the below-named distributees.
2. The. value of decedent's entire probatable estate,
wherever located, less liens and encumbrances, does not exceed
$150,000.00.
decedent.
More than thirty days have elapsed since the death of
4. No application for the appointment of a personal
representative is pending or has been granted in any jurisdiction.
5. Decedent died without, a will. The individuals named
hereinbelow are the surviving children of decedent. Diane Atwood
was the surviving spouse of decedent, but she passed away on May
12, 2005. The Estate of Diane Atwood and the surviving children of
the decedent are the sole heirs of the decedent under Wyoming's
laws of descent and distribution. There are no other distributees
of the decedent having a right to succeed to the property under
probate proceedings or under the laws of descent and distribution
in the State of Wyoming or any other state:
a The Estate of Diane Atwood, spouse since deceased, 16
Gomer Street, Diamondville, Wyoming 83116, 50% of estate;
b Terry Atwood, of legal age, son, 1480 North River
Bend Drive,. Green River, Wyoming 82935; 10% of estate;
c Carol Atwood, of legal age, daughter, 109 Barrett
Avenue, American Fork, Utah 84003, 10% of estate;
d Mike Atwood, of legal age, son, Route 1 Box 19,
Fairview, Utah 84629, 10% of estate;
e Robin Smith, of legal age, daughter, 9826 NE 140th
Street, Bothell, Washington 98011, 10% of estate; and
f Tiffany Atwood, of legal age, daughter, 7017 144th
St. SE, Snohomish, Washington 98296, 10% of estate.
The abovednamed distributees are entitled to payment or
delivery of all accounts receivable and property which belonged to
the decedent.
6. Ail tangible personal property, including but not
limited to that stock specifically named below, authorized by
Wyoming Statute ~2-1-201 to be distributed by affidavit shall be
made payable and/or delivered and/or set over 50% to the Estate of
Diane Atwood, 10% to Terry Atwood, 10% to Carol Atwood, 10% to Mike
Atwood, 10% to Robin Smith and 10% to Tiffany Atwood.
is more particularly described as follows:
166.67 shares of stock in T B R Constructors, Inc.
Said stock
7. Any person or institution transferring property of the
decedent in accordance with this affidavit shall be held harmless
and a receipt from any distributee is a valid and sufficient
release and discharge for any such person or institution in regard
to transferred property.
8. This affidavit is made in compliance with W.S. 2-1-201.
9. A certified copy of the Certificate Of Death is attached
hereto and by this reference made a part hereof.
DATED this
day of ~ , 2005.
The State of Wyoming )
: ss.
County of Sweetwater )
The forgoing Affidavit For Distribution Without Probate was
subscribed and sworn to before me this _9 day of
~____, 2005, by Robin Smith. -
Witness my hand and'official seal.
My Commission Expires:
-2-
~'ti' I'egal Name (l~clud~',~,l~'~il a~, Fi(~I _;) '¢-.M ~U ~ ~:'". ~ '~LA~¥~ ,' /' '.. ' .~ulf ~'.." )-De~th Da"~TM '''~ """ ...... ;
;':":J ':: Albe~"'?.....~ .:]~:x;7~:~ 7%'.~ ';".;r~.r.:;~' ~TwoOD, ':;,.:,.:,:~ 7 Peb~a~24. 2005
Male :/ .' ." 65":' ~ paaa; ..... ?6a;~:---TT'p;a;;":-'-v'a;ta;7'-*-I , 52746}2318
3. Sex MIF) · ~a. AgeF:kast ~iahday ~. Under 1 Vefir' ': ~c. Under ~ Da~ 7" ~. Social SecuriIy Number ~. County or Death
5.'7. Bidhda/e "~a[.Bi~hplace (~i~y. townjm.copnty) ~b. (stoic or Foreign CounW) " ~. DecedenPs Education
~ November26, 1939/"'Evanston"·" / Wyoming/High School Graduate
i. 10. Was Decedent of Hispanic Odflin9 (Y~s or No} It yO~ ~po&tT. ~ 1. Decedent's Race(s) 12. was Decafl~nl ~wf in U.S.
{':No White
Armod Forces? N0
~ aa. Residence: Number and Street (~.~., ~24 SE 5~ St.) {lnclu~* ~1.
16 Comer Street ~ ~b. city or TownDiamondville
~3c. Residence: County 1ld. Tribal Resemation Name (if applicabl~} 13~. State or Foreign Countff 13f, Zip Code + 4 ~. Inside Cit~ Limits~
LNcoln " I Wyoming 83116
~.~14. 45EsfimatOdyearslen~lh of limo at residence ~ 5. Marital: StatUSMa~edat T/mo of D~a~ 1 *.DianeSU~ivin~PodlesnikSP°use's Name {~i~o nam~ prior lo first marria~o}
g Con=actor Construction
~ 1 ¢. Father'~ Namo (Fitsl, Middle, Last, Suffix} 20. Mothor's Namo Before First Marriage {First, Middle, Last}
[' Albe~ A~ood ' Maw Lavma Owe~
~' ,il Informant's Name ~2~ Relalibnship to Decedent ,a. Mailing Address: ............. ,F~ No. Ct,, ~ Tow, S .... Zip
~: Rob~ S~nith~ Daughter~ 9826 N.E. 140th St., Befell, Washington 98011
Inpatient
¢ ZS. Facility Name (ii nme facilay, gi ..... bey ~ s~,,t or l~adgn ~6a. City. Town. or Location of Death ~6b. S/ale ~7. Zip Code
::.: Overlake HospitalMedicalCenter ' ~ Believe ~ WA~ 98004
: ~8. Method of Disposition ~9. Place of Final Disposition {nam~ el ~mam~, c~emalo~, other place) ~0. Location-C/tyCoon, aha State
Cremation [ Bays/de Cremato~ / Seaule, Washin~on
M. Name and Complete Address of Funeral Facility ~2. Date o~ Disposition
~:: Wiggen & So~ Funeral Home, 2003 ~ 57~ St, Seaale, Washin~on 98107/ March 1, 2005
1 14. Enter tho chai~ of ovents- fl ~oases, injuries, or complications - that Oirectly cause~ the death. DO NOI enter terminal ewnts su~ as cardiac arrest, respirato~ arrest, or
~tentdcularfibdllationwi~outshowin9thoetoogy DONOIA~BREVtAIE. Add a0ditional lines if noc~ssa~.
MMEDIATE CAUSE (Final aiso'a~o or ~lnlemal belwaan Onset g Death
:0ndition result/n9 in doan) 4 a. ' ~ ~ ,,
hat initiated the events resulting in c: ~?~
~eath)~ST ' : ' : ' ., Due to (or as a ~nsequen~ o0: llnte~al be~een Onset &
15. Other siqnificant conditions contdbutinq to death but not resulting in the underlying cause given above ~6. Autopsy? 37. Were autopsy findings available to
~8. Manner of D~ath ~9. If femal~ 10. Did tobacco use contribute
~tural ~ Homicide ~ Not pregnant within past year ~ Not pregnant, but pregnant within 42 days before death lo death?
~ Accident ~ Undetermined ~ Pregnanl at time of death ~ Not pregnant, but pregnant 43 days to 1 year before death ~ ~ Probably
~ Suicide ~ Pending,. ,. ~ Unknown if pregnanl within the past year ~ No ~ Unknown
~ 11. Date of Inju~ Iu~OD~W'' ~2-H0ur of '~Juw (24hrs)~3. Plaea of 'njuw (e.g.. Dacedem', h ....... ~uctionsi t , ...... ..... .... tied .... ) 14. ,njuw at Work?
:/ "/ ~ Yes ~ No ~ Unk
16. Describe how injuw occurred 7~ If transpodation injuw, specie:
.:: ~[~ Driver/Operator ~ Pedestrian
.. Passenger ~ Other (Specie)
1Sa. Cedifyinq Phys c an-to t i~ ~ of ay:~a'o~[e~oe, deatfr~cct~:red}~t ~e lin,e daie. and tSb. ~edicalfExaminer/Coroner - O~ f e bas ~ of e~a at :r. andlul in'~estigaticr, in my
I p,~ ~nd/,~o ,, .... t,¢~) and .......... ta~.:' ..... ~... ' op,nior, d_:atl .......... o ,it ,he lime. d ...... -,,g ....... d alu, to ,, ......... rs, and ,r ........... ted
, a. a - v NE',BSlle~e WA~ 0}~' ,' .... O , ' 16:15
51. Name and Title of Attending Physician if other '"'¢, Ce,ifie(.(~ :~:~*" . '~:~E/,X ' 52.
..~,.Am¢"~m"nt~ ....... "'~ {, '5: ¢,;:/** ,'~;'~ ~/~X~':'~' ~:" ;,.. -; ~,-," ....
..... ,, ,., ........ . : ..... ............ ~,, ~,~..-~--.,' ,, ..... . :. .?: ;'....,. ~:~
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