HomeMy WebLinkAbout915786
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RECEIVED 2/6/2006 at 11 :22 AM
RECEIVING # 915786
BOOK: 611 PAGE: 592
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
----~-Æffiu-avit of Survivorship
,OC592
Eugenia C. Beck, of lawful age and being first duly sworn upon her oath deposes and states
as follows:
1. She is a person with personal knowledge of the facts set forth here in below.
2. Affiant and Thomas G. Beck owned certain property as follows:
a. The land located in the County of Lincoln, State of Wyoming described
as follows:
LOT SIXTY - EIGHT (68) IN STAR V ALLEY RANCH PLAT
SEVEN (7), Lincoln County, Wyoming
3. Thomas G. Beck died onq~~ ;J. {¡ ;{oo3 ,thus ending his interest
in said property.
4. A copy of the death certificate of Thomas G. Beck is attached.
5. Affiant has created the Eugenia C. Beck Living Trust dated September 23,
2005. A copy ofthe Certificate of Trust is attached.
6. This affidavit is made in support of said property being in the sole name of
Eugenia C. Beck and then in the name of the Eugenia C. Beck Living Trust
upon her executing and recording a deed so transferring it.
7. This Affidavit is made in conformity with Wyoming Statutes 1997, §§34-11-
101 et seq.
8. Further affiant sayeth not.
141
Dated this ~g -day of
/J.¿~ ,2005
fo~ (}&~_
Eugenia C. Beck, Affiant
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00593
STATEOFV{YOMING m~/Za-)
{ja//crhi-L ) ss
COUNTY OFNATRONA )
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The for~instrument was acknowledged before me by Eugenia C. Beck on this au
day of ;.url èJ.J , 2005.
WITNESS my hand and official seal.
~~Culmr
Mo/rr:;:;;:;:a ¿MtI1
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_·,:;rc~''''''''').!:,·-l....,-a....~~...~.'1.''''-.'':' '-',~ :;.' ;.;.~..;:,:".. . ,·... .~~~·~~õ¡·~~~,\',."~h....·:r.....;;-,..',~':.,;I;,'¡~4~·,'. ; :,.t.:.····.·; ,~:...:~:.¡;~.~~.~.,'~~.;_..,.,._ "..J..-..,....,--'''-.:I'..~,.".
~Male . 309-22-1057
14. PLACE OF DEAìH
.... HOSPITAl 3 Inpatient 0 ERIO
.B FACILITY NAME (If nol Institùtioo, give slreel and number)
~ I~Deaconess Billin s Clinic-Hos
.... IRniPlACE (City, and State 0( foreign Country)
i5 0 Widowed Ia Man1ed
_ . Terre Haute Indiana 0 Man1ed bul separaled D Divorced D UÑ<nOwn
C'O DECEDENT'S USUAl OCCUPATION(GIYoWndol__œ,mgmollof-ndnglife. KIND F BUSINESSIINDUSTRV
.... (Do nol use ,elnd)
ê -Sales Mana
:J a. RESIDENCE· State
~ MT Gallatin
:...: 1. DECEDENTS EDUCATION
..., rriy the ~ dIpIomo or degee .-I-..d)
CO 8111 grade 0( less
"'0 9th . 12th gade: No Diploma
2 High School gnoduàte 0( GED compleled
( J Some college but no degree
ëi. Assoclale degree (e.g. M, AS)
E BaclÍ/;lor's Degree (e.g. BA, .'-8, as)
o Maste(s Degree (e.g. MA, MS, MEng, MeII, MSW,
o MBAI
D Doctor~1e (e.g. Pt1D, E!lDI 0( Prolesslonal degree (e.g
( J MD DDS DVM llB JD
CO 11. FAìHER'S NAME (Ars~ MldcIe, Lastl
~ Geor e J" Beck
138. INFORMANrS NAME
f'S1.5786MoNTANA CERTIFICATE OF DEATH
, nr59.4
'._' ,...~ "a .
State File Number
Thomas
Sex
Ha es
WAS DECEDENT EVER IN U.S.
ARMED FORCES?
. 3Ves 0 No
11. ZIP CODE 7g. INSIDE CITY
UMITS
Bozeman 59718 Q :vesDNo
. DEC ENT OF HISPANIC ORIGIN? ~ the box ""'. - 53.DECEDENT'SRACE (~.... or........ ,ocel .. IndIcete what the _nO.
I __ the deQedenlls SpanlsMilsponlcllllno. -. _ or _.. bel
Ched< the 'No" box . "'" -... Is not Sponls<1ilsplnlo.1..allno. ~te OSamoan
Black African Amet1c:an 0 Other AsIan (Speclfyl
Native Hawaiian
Asian Indian
Chinese
o Aiiplno 0 Amel1can Indian or Alaska Nativlt (Name
o Japanese of !he ervolled 0( pñ:>c!pal Irtbe)
o Guamanian 0( Chamono
o Korean
o VIetnamese
Dr
3 No, no' SpanlsMilspaRciUtino
o Ves, Mexican. Mexican American, CNcano
o Ves, Puerto Rican
o Vaa, Cuban
o Ves, o!har SpanlsM-llspanlclLaUno
(Speclfyl
(p1her Pacific Islander (Specify)
o Oilier (Speclfyl
12. MOìHER'S NAME (Ars~ Middle, last name before first mamagel
Bernadine Wa er
RaATIONSHIP TO DECEDENT MAlUNGADDRESS ($_..nd,.._ 0/1 Ru..1 Rou1a ,.._, CIty or To.... Stole. ZIp Codel
Eu enia Beck
MEiHOD OF DiSPOsmON
Ia Burlal D Cremation
18.0 Enlombmenl' 0 !Ion
~NAruREOF ~ R
OF DISPOSmoN
22-
ITEMS 24-28 MU T BE
o Removal from Slate
Bozeman MT 59718
LOCATION· City or Town, Slate
MT 59715
zr. lICENSE NUMBER
28. DATE SIGNED (MoIDaylYeat)
. ACruAl OR PRESUMED TIME OF DEATIi 31. WAS MEDICAl EXAMINER OR CORONER CONTACTED
o Ves !a No
02:00A
CAUSE OF DEATH (See Instrucllonl and examples)
32. PART I Enlarthe dlaln of __ - _.... Irý.JrIoo. or ........._ . .... chc:IIy __ the de.th. DO NOT _ _ e_ ..... .. __ or ......Iory .......
or --...... _lion _ ....wIng the eliology. DO NOT ABBREVIATE. EnIar rriy .... _.. on each _ Add _ lIMo . --.y
.... iMMEDIATE CAUSE(IInaI__ or
G) 00ncIII0n .....1IIng In deathl
r¡:
:e
G)
()
ApprwImeIe "'-
Be_ Onoe. Ind ea.th
} e.
Sepsis
DUE TO (OR AS A CONSEQUENCE OF):
Days
")
::J
::J
....¡
}b.
DUE TO (OR AS A CONSEQUENCE OF):
ëii c. Colon, resection for - Colon cancer
o DUE TO (OR AS A C::>NSEQUENCE OF):
:g d. cachexia
:æ PART liEnlet' oIherslnnificanl condI6ons eonlr1bu61'C 1o death but not resulting In the undet1ylng cause given In Pel\ 1
>. 1. Severe congestive heart failure 2. End stage renal diseas
~ 3. Severe vascular disease
( J :J1. MANNER OF DEATIi 35. DID TOBACCO USE CONTRIBUTE
ã) !8Naturel 0 Homicide TO DEAìH?
ëi. DAcckIenI 0 Pending Investigation D Ves 0 Probably
E Suicide Could not be Delermlned 0 No
o DATE QF INJURV TIMEOFINJURV INJURV AT WORK
o (Month, Day, Vaat)
38.
( J
CO 43. DESCRiBE HOW INJURV OCCURRED
Sequentially list conditions II ant.
Ieacing 10 cause Usled on Hne a. Enter
UND£RLYING CAUSE(DIoeaM or ~ the.
_ e_ _1IIng In death.ILAST
Das
Days
\.;ïeeks
'"
WAS AN AUTOPSV PERFORMED?
33. D Ves Q :No ,
. WERE AUTOPSV FINDINGS AVAIlABLE PRIOR
o COMPLEllON OF CAUSE OF DEAìH
o Yes No
::>
39.
1. DYes 0 No
38. IF FEMAlE
o Not pregnanl within pest yew 0 Pregnant at time 01 deelll
No pregnant but pregnenI willi 42 days of dealll 0 Unknown II pregnant within pesl yew
No pregnenI but pregnenI 43 days 10 1 yew belore deeth
40. PlACE OF INJURV (E.g. -..rl _, ConIfruç on 4-4. iF TRAFFIC ACCIDENT SPECIFY
SIIe. -....... - ....1 0 DrlvetlOperator 0 Pedestrian
Pessenger 0 Other (speclfy\ , ,
LOCATION ($..... and,.._ or RuralAoute _, CIty. Town,
Stole. ZIp Codel .
:0
.w
.A-
TO BE COMPlETED BV CERTlAER (A C8f1IfIeI cari·be a MD, PA, APRN, 0( coroner)
'fylng Physician: To the besl of my Knowledge dealll occurred el the time, date, end place and due 10 cause(sl
PronOünclng~lcIan: To the _0' "'f Knowledge death ocx:uned a' "'" _, date, and place and...... _..(II and """"'" sta_
Medeal Exami the b~1Ion _1nwsIIga...... In "'f opinion. delth """'rM I. the _ and place and.... .. the -oe(x)
and_"'_ ' '
SIGNATlIAF' ,
MD
46. NAME AND ADDRESS OF CERTIAER (PHVSICIAN OR CORONER) (Type 0( Print)
Gregory Mock M.D.
2825 8 " North Billin s MT
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03:15786
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STATROFMONTANA,}, '
County òf Y'ê1}þwstooe,- · .1
I cer11fy that ff1.is in$frument Is.
trU13 r COO1pt¡Jtô and COfroct oopy
of ttJe origkldl on file in my omce.
Wltne8S my hand and seal of of11co.
~
FES 0 4, ZUUJ
----0--'----
Date
A E, County Clerk 1114 necorder
by
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