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RECEIVED 12/19/2005 at 1 :26 PM
RECEIVING # 914538
BOOK: 607 PAGE: 758
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
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AFFIDAVIT OF COLLECTION AND DISTRIBUTION OF
DECEDENT'S PERSONAL PROPERTY
The undersigned, being first duly sworn, on oath depose and
state that we are making this affidavit pursuant to Section
2-1-201, W.S.A. (2005), on behalf of ourselves as distributees, as
hereinafter set forth, and that we make the following statements in
connection therewith:
1. That Amy Rose Peternal, a/k/a Amy Peternal, died on
October 28, 2005, in Lincoln County, Wyoming, and was a
resident of Lincoln County, State of Wyoming, at the time
of her death; that said decedent died intestate; that we
are the sole and only parties entitled to the property of
the decedent pursuant to the laws of the State of
Wyoming.
2. That the value of the entire estate subject to
administration
wherever
located, . less
liens
and
encumbrances, does not exceed $150,000.00.
3. That more than thirty (30) days have elapsed Slnce the
date of death of the decedent.
4. That no application or petition for the appointment of a
personal representative of said decedent is pending or
has been granted in any jurisdiction.
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5. That the only personal property owned solely by said
decedent not otherwise disposed of is the following:
First National Bank ... West
Savings Account # 10063741
6. The undersigned request that the remaining balance In
said account be distributed to Otto D. Peternal.
DATED tr-lis
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ELLEN T. PET};:RNAL ",
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LUéy A,) H'ILLSTEAD
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THE STATE OF WYOMING
COUNTY Q[j)~C C)~a
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this
The above and (oregoing instrument was acknowledged before me
I~ day of t::';:,\C~QJSl\()L',-.-J 2005, by OTTO 8. PETEEN.L\.L.
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WITNESS my hand and official seal.. ''\
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THE STATE OF !&YOM-I-NG--Ccu.¿·{VO
COUNTY OF
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The above and foregoing instrument was acknowledged b2fore me
thi s '7 'ih day of 7)ZJ~2F-!~':/ 2005, by ANN M. PETEr<.m\L.
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WITNESS my hand and official seal. / /
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" '-' L. ~L 1 L U . "- -" ',/ ROXANNE REYES
My Commis~ion Expires:
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THE STATE OF WYOMING
ss.
COUNTY OF
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i C(O;I,t~'.~TN~¡~;,~';) mY~Òìp~d 4nd official s~ef)l.
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My Commission EX~ires:
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Notary PY.\llc
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THE STATE OF WYOMING
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Th~ above and fo~.~~gOing instrument was acknowledged b:fore me
this 10 day of ~,JjU(2-1~JltQ/\'~ ,2005, by LUCY A. HILLSTEAD.
WITNESS my hand and official S:øa..l. "r. L
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.: Count} oi ":;1 't, State of
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.' Lincoln 'd ¡'yommg
I Mv commiSSiOI:'EXp¡r:: AogU3t 16, 2000..
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