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Home My WebLink About929790 ''If 00059(:; AFFIDAVIT OF DISTRIBUTION STATE OF WYOMING ) )55. COUNTY OF LINCOLN ) Candice May Lancaster and Jessica Lee Lancaster, being first duly sworn, on oath, deposes and states that they are making this affidavit pursuant to W.S, § 2-1-201, as distributee's, as hereinafter set forth, and that I make the following statements in connection therewith: 1. That Blake W. Lancaster, became deceased December 16, 2006; that said decedent died intestate; that the decedent at the time of his death was survived by his two children Candice May Lancaster, 6821 Maury Dr., Olive Branch, MS 38654 and Jessica Lee Lancaster, 13462 Peardale Rd. Grass Valley, CA 95945. 2, That at the time of Blake W. Lancaster's death he was the owner of a life insurance policy with Beneficial Financial Group, Policy #BL0713019 and that Sybil W. Lancaster, his Mother, was named primary beneficiary and Delmar C. Lancaster, his Father, was named contingent beneficiary. 3. That attached hereto is a copy of the Certificate of Death of Blake W. Lancaster and is attached hereto as Exhibit "A". 4. That Sybil W. Lancaster, the named beneficiary of the above referred to policy became deceased on August 10, 2006 in Afton, Lincoln County Wyoming, and attached hereto and marked Exhibit "B" is a copy of the Certificate of Death of Sybil W. Lancaster. 5. That Delmar C. Lancaster, the contingent beneficiary became deceased on May 21, 2006 and that attached hereto marked Exhibit "C" is a copy of the Certificate of Death of Delmar C, Lancaster. 6. Since the named beneficiaries of the above referred to policy predeceased Blake W. Lancaster, the proceeds of said policy are therefore payable to his two (2) children Candice May Lancaster and Jessica Lee Lancaster. 7. That the value of the entire estate of the decedent, Blake W, Lancaster located in the State of Wyoming, does not exceed the value of One Hundred Fifty Thousand Dollars ($150,000), 8. That more then thirty (30) days have elapsed since the death of Blake W. Lancaster. RECEIVED 5/29/2007 at 12:23 PM RECEIVING # 929790 BOOK: 659 PAGE: 596 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER. Vfi 000597 oJ' r:i'-¡3'~Î\ \'''¡~'\ >..~ t 'Ù 'U"-,,N' 9. That no application for the Appointment of a Personal Representative of said decedent is pending or has been granted in this jurisdiction. 1 O. That Candice May Lancaster and Jessica Lee Lancaster as surviving daughters of Blake W. Lancaster are the sole and only parties entitled to the proceeds of the above referred to insurance policy; that there are no other distributee's or beneficiaries of Blake W. Lancaster having a right to succeed to said insurance policies under any probate proceeding; therefore, the following named distributees are entitled to payment and delivery of the proceeds of the above referred to policy: Candice May Lancaster, one-half (%) interest, Jessica Lee Lancaster, one-half (%) interest. 11. That among the assets owned by the decedent Blake W. Lancaster at the time of his death is the following: (a) Funds held by Beneficial Financial Group due and payable under policy #BL0713091 on the life of Blake W. Lancaster, deceased. 12.. That an executed copy of this Affidavit is being presented to Beneficial Financial Group in compliance with W.S. § 2-1-201 (a) and that said party is requested to pay the proceeds of said policy of any other funds in said account that were due and owing to the decedent, together with any interest and dividends thereon to the distributees above named; Dated this 3D- day of ~, 2007 œÁ~' Can . Lancaster STATE OF MISSISSIPPI COUNTY OF 'J)pSo-b ) )ss ) The fOre~} instrumenL':::?~, ~cKn01. as, cknowledged before me by Candice May Lancaster, this ""' day of ~, 2007. WITNESS my hand and official seal. ~~t~ NARY P LlC MY COMMISSION EXPIRES: SEPTEMBER 7, 2010 2 Ò~2:r?~O STATE OF CALIFORNIA ) )ss COUNTY OF ) ~~~ Jessica Lee Lancaster The foregoing instrument was acknowledged before me by Jessica Lee Lancaster, this day of 2007. WITNESS my hand and official seal. 000598 NOTARY PUBLIC 3 Q~Z9?90 CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT ~~~~~~ 00059~1 State of California County of N e.lÞa:>A }$ NI~I -ktN~N ~y'fD~c. Name and Title of Officer (e.g., "Jane Dóe, Notary Public") On fhA'f (ï. "Z-oo'"'1, before me, Date personally appeared .j~SG(C-A L-Ee:. ~'""E1Z-- Name(s) of Slgner(s) o personally known to me r"'u:: 1!tiì&UI -e ~#I6G30 I -_.~ ,...,.. ea.nr _Camln..........1 -- 4. __ __ ~ . ~ .. 11&1 4. .I~~ :¡t proved to me on the basis of satisfactory evidence to be the person~ whose name~ is/§Vé subscribed to the within instrument and acknowledged to me that þé/she/tþeY executed the same in I)jS7her/the1f authorized capacity(~, and that by ~er/tþeff signaturef.S1 on the instrument the person~, or the entity upon behalf of which the person~ acted, executed the instrument. Place Notary Seal Above OPTIONAL Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent fraudulent removal and reattachment of this form to another document. ..-_.- Description of Attached Document Title or Type of Document: -------- Document Date: Signer(s) Other Than Named Above: Capacity(ies) Claimed by Signer(s) Signer's Name: o Individual o Corporate Officer - Title(s): o Partner - 0 Limited 0 Ge o Attorney in Fact o Trustee o Guardian or Co o Other: RIGHT THUMBPRINT OF SIGNER Top of thumb here Signer's Name: o Individual o Corporate Officer - Title(s): o Partner - 0 Limited 0 General o Attorney in Fact o Trustee o Guardian or Conservator o Other: RIGHT THUMBPRINT OF SIGNER Top of thumb here Signer I Signer Is Representing: -. -. -. -. -._.-.-.~~ (CJ 2004 National Notary Association' 9350 De Soto Ave., P.O. Box 2402' Chatsworth, CA 91313-2402 Item No. 5907 Reorder: Can Toll-Free 1-800-876-6827 {}~J297SÜ COUN"I'Y OF' PU<CD AQbtU'Q" Cª,tUQ<fQ¡ta ,s:m 000600' .~ ~ I :~ ~ I ..~ ~ I ~ I I I .~ ~ I ~ I ~ .~ ~ I . I CERTIFICATE OF DEATH SToVE. OF CAUfOAMA uselUCK..øuJ~~VS~fEOUTSOftAlTERAOONS 2. MIDDLE 3. LAST (Family) LOCAL AEGISTRA110N NUMBER 3200631002755 STATE FILE NUMBER 1. NAME OF DECEDENT_ FIRST IGIvtnt BLAKE ~ ..... ALSO KNOWN AS -1_ "" AKA ,,,sr. MIDClE,lASl) I ~ fa Id Q IN 19. YEARS IN OCCtJPATfON Timber Feller 25 20. DECEDENTS RESIDENCE Strftt If1d numbW, CII' Icx:MIon) ~ I, 14630 OLD CANP'l'ONVILLE ROAD !!¡! 21. CITY 22. COUNTYIP~E 2 CilMPl"ONVILLE . YUBAl U i!i ~i II Ii I~ 28. 1NF000000S NAME, RElATtONSHIP DENNIS ¡q. LANCASTER BROI'HER 21. NAME QF SURVIVING SPOUSElSAOP"-FJRST.; . .~\~; 3D. LAST (BIRTH NAME).:. 31. NAME OF FATHERIPARENT-FIRST DEU1I\R 32. MIOClE CLYDE 3S. MIODI.E ... á<AtH &rATE IN 33. LAST LlINCAS'l'ER 37.l.AST IBIRnt NAME) ýolAL'roN 31. BIRTH STATE Ý'1Y 43. UCENSE NUMBER 7711 K/\¡'¡ 101. PLACE OF DEATH SUTTER,MSEV1LLE'MEDÏcAL'CENTER ~§ J 104. COUNTY PLÄCER' ~eiJlAÝE CAUS~' ,;~ =.:"~-.' ,,- 1"1, -0I0IIy.... i c;or¡dIlIoN,lIlII'Iy. ~.~C=: ~ UNDERLYING ~ =--..... . inIU"dlh._ IDI 5 NaIlIng In ..UIt lAST 113. WAS'OPERATION PEFlfORMED FOR ANY ~IN ~M 107 OR 1121 (I'JN. III IVJ* 01 opøUIon and ~'.I It..IŒRTfY TtWTOTHE 8EsTCIf UYKHOWl£DG&DfRHOCCURRED 115. SIGNATURE AND mu OF ŒRTIFIER ATTHEHCIUR. OOE, NÐPlACf: STATED FAOAI TME CAUS£saWED. .DIe""" AI.... sm. D~ lnI ~AIIvI þ) (A) mmIddIc:CYY ¡ (8) mmlddtœw II 111. VSIC 'HAM. 111.1 CERm THAT IN MY OPtION DEATH OCCUAÆDIifTHEHOUR. DAlE,AND F\AC£8TATEDfROtd THE CAUSeS sweD. ~CFœA~O- 0-0- 0"'- ŒJ=,.. 0== i 123.. PlACE OF INJURY lag.. home, CCNlructlon Iit_, WOOIMd area; ... ~ E I 120. INJURED AT WORK7 121.INJURVDATE ønMdICCyf 122.HQIJR IMHøuraI OveSONO 0- 124. DESCRIBE HOW tNJURY 0CCUfVWJ IEYMIS whIch.........t In Injury 1as,lOCATION OF INJURY (SIIMI n ftUn'Ibw, or IDeatIon. and clCr. and z/pI \ I 127. DME rnm/dd,Iccyy 121. TYPE e. mu. OF CORONER I D£PUTV COAQNER 12/19/2006 DENNIS H. WATT, DEPUTY CORONER FAX AUT1U 26769 CENSUS TAACT CERTIFIED COPY OF VITAL RECORDS /111///11///11111111/1//1/11111111111//111/1/1111111111 *000229330* } 88 STATE OF CALIFORNIA COUNTY OF PLACER DATE ISSUED 04/09/2007 This Is a true end exect reproduction of the document officially registered and placed on file In the office of the Placer County Heallh and Human Services Department. ~ Richard J. Burton, M.D. HEALTH OFFICER ANO LOCAL REGISmAR This copy not valid unless prepared on engraved border displaying seal and signature of Registrar. ~- ,.,1··.".· .:~ ",\'-. {)~29790 C01UJINfIY O)T PLAcu A\lb"rQ~ CattfvQtt\ t$6~ STATE "1&.1: NUMBER PHYSICIAN/CORONER'S AMENDMENT DEATHS AFTER 1·1994 NO ERASURES, WHmours, OR OTHER ALTERATIONS USE BLACK INK ONLY J 1 Dolo 3} OD2ì S- ç- LOCAL REGJ8TRATION DISTRICT "NO CERTlf'lCATI!: NUMBER 00060:1 8. CITY OF OCCURRENCE ROSEVILLE :3. LAST ,".WILY) ¡LANCASTER :7. COUNTY OF OCCURRENCE ¡ PLACER :4. SEX ¡ M ~.. I ~ , I ~. I ~ ï I I I ! I I ~ I ~ I I I i I I I I ~ I I I :~ I ~ ..~ I ~ ..~ ~ I PART I NAME AS IT APPEARS ON RECORD ADDITIONAL. 8. DATIE OF EVENT-MMIDD/CCYY r';¿'A';.'::....r;,':,7,: 12/ 16 / 2006 INFORMATION TO LOCATE RECORD I. NAME-I'IRST JGIVENJ 12. MIDDLE BLAKE ! WALTON PART II STATEMENT OF CORRECTIONS o. ClEtmlttCA~ e. INFORMATION AS IT APPEARS ON ORIGINAL RECORD "". ""..... 1 O. INFORMATION AS IT SHOULD 'APPEAR UST ONI! ITEM ÆR UN&; MULTIPLE BLUNT FORCE TRAUMA (HOURS) HYPERTENS~VE CARDIOVASCULAR DISEASE PROBABLE. T EROSCLEROTIC CORONARY ARTERY V 3. REACTIVE AIRWAY DISEASE (ASTHMA) PROBABLE. PENDING INVESTIGATION ACCIDENT NO 12 1 1500 AIRPORT DECEDENT WAS TIIE>SO OÖ OF AN AIRCRAFT THAT CRASHED;' INGERSOLL AIRPORT, INDIAN RANCH ROAD, DOBBINS, CA. I HEREBY DECLARE UNDER PENALTY OF PERJURY THAT THE ABOYE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. DECLARATION OF CEATlII'YING ~YSICIAN OR CORONER : I 2.. DATE SIGNED-MMlDOICC:YV 13. TVP'ED Oft PRINTED NAME ANO TITLElOEGREE OF CERTII"IER 02/01/2007 DENNIS H. WATT, DEPUTY CORONER 11500 A AVENUE ~,.,IS. CITY :16. STATE ,17. ZIP'CODE ! CA i 95603 11. DATE ACCEPTED FOR REGISTRATION-MM/DD/YY STAT£ILOCAI.. REGISTRAR USE ONLY :. OFFICE OF VIT~~NATURE OF LOCAL REGISTRAR f..1), 02/14/2007 STATE OF' CALIFORNIA. DEPARTMENT OF HEALTH SERVICES. OFFICE OF VITAL RECORDS VS 2....IRf'I. 101031 STATE OF CALIFORNIA COUNTY OF PLACER } SS CERTIFIED COPY OF VITAL RECORDS 1111//11111111111111111111111111 ¡Illl 1/1111111111111111 *000229331* DATE ISSUED 04/09/2007 This Is a true and axact reproduction of the documant officially registered and placed on file In the office of the Placer County Health and Human Services Department. ~ Richard J. Burton. M.D. HEALTH OFFICER AND LOCAL REGISmAR This copy not valid unless prepared on engraved border displaying seal and signature of Registrar. aTATII ~ .......... COUN1rT 011' '¡U<CD 000602 A"b\u"JJ~ CattfQX'Qiª tS~ AFFIDAVIT TO AMEND A RECORD 32/)Ö¿,3/ÒtJ"L 7 S-S"" DEATHS AFTER 1-1994 LOCAL ...œn"ATfDN ÞI.TItlCT AND C.ImP'IC.U. NUIroI.... NO ERASIllES, MlTEours, OR ALTERAT~NS 'O~29?~G PART I INFORMATION TO LOCATE RECORD-TYPE OR PRINT IN BLACK INK ONLY ¡~ ¡~ = ~ I I I I I ~' I I ; ~. ~ I ~ i STATIlAOCA~ '1" REØISTAAR us. ON~Y NAMI! AS IT I. NAME-PIRST (GlgN. AP:~~:OON BLAKE I 2. MIDDLE I WALTON I 3. I.AST (I'AMIL \1 I LANCASTER . ACOIT1ONA~ INFORMATION TO LOCATE RECORD .. SEX S. DATE OF EVENT-MM/DD/CCYV M 12/16/2006 8. PATHeR'S NAME AS STATBD ON ORIGINAL Delmar Clyde Lancaster e. CITY OF OCCURRENCE Roseville I 7. COUNTY OF OCCURRENCE! I Placer I , I I I ~ I I ..~ I , I ~ ~ ~ II. MOTHER'S NAME AS STATED ON ORIGINA~ sybil - Walton PART 11\ STATEMENT OF CORRECTION&--:.No ERASURES. WHITE OUTS, OR ALTERATIONS , 10. CUnl'lCAT II. INPORM~TON AS' IT' APPEARS ON ORIGINAL-_ RECORD 12. 'INPORMAi'ION AS IT SHOULD APPI!AR .,.... NUU..A " .' 2 Walton W. 11 . Never ~rried Divorced ..... . ..... UST ONE " .' ITEM FER UNE :- c ¡- .,,' ': .' ,". " ,..' ". '." ,I 'F ! ",' , " .' T. '7' c, ... '",. " .' , . , . ., , .<'{ , ,,' '. , I __" I' '.., ,,"., " 0 I ~ -.- / I ,,' : >, ""', , ". ' .: c ·.Y··'" ". ... " ' " . , ( , , ,'. " ',,',-7 '7 '. ',"," . C, REASON FOR IS. Incorrect information 'riven on original. CORRECTION -.:c- " .".,' ",' , . "" " APFIDAVITS We. the undersigned, hereby certlly underpenslty of perjury thai we have personal knowledge of the above facls AND SIGNATURES and that the Information given above Is true and correct. :. S¡¡;U;E7 ~~Slã1~ . . : 111. TITLe/RELATIONSHIF TO PERSON IN PART I : 18. DATI! SIGNED-MM/OD/CCYY TWO I Funeral Director I 02/09/2007 PE'iiiõNs ; MUST SIGN 17. AGIt,' r·' 8. ADDRI!~sgsTRBIT. CITY. 8TAT" ZIP) THIS FORM Lellal ! 250 Race St., Grass Valley, CA 95945 ':;;'77E.OF SECO~~SON -I.. : 20. TIT~ElRELATIONSHIP TO FERSON IN PART I 121, DATI!! SIGNED MM/DD/CCYY use : .sz 1'1/2007 BLACK INK W. (L,' Brother ONLY 22. "'~ 't 23. ADDRESS 18TH_lIT, CITY, STAT" ZII'J Lellal I P.O. Box 1589, Afton, WY 83110 I STATEILOcAL 24. SIGNATURE OF STATE OR ~R as. DATE ACCEPTeD FOR REGISTRATION-MM/DD CCYY REGISTIIAR Þ- .~- ¡JJ ,02/ 28'/2 DO 7 USE ONLY I 1 II STa £ Of CUIIIIaA, D£PIIITIIDII Of 1ÐI.1H SOIIC£S, IJffIC£ tJf iliff It:GlSllAI ""Il) ChI. 1/ ) STATE OF CALIFORNIA } COUNTY OF PLACER ss CERTIFIED COpy OF VITAL RECORDS 1/1/1111/1111111111111111111111111111111/11111111111111 *000229332* DATE ISSUED This Is a true and exact reproduction of th!?jm!t gic~te;t2£n? placed on file In the ollica of the Placer County Health and Human Services Department. ~ Richard J. Burton. M.D. HEALTH OFFICER AND lOCAl REGISTRAR This copy not valid unle~s prepared on engraved border displaying seal and signature of Registrar. ~ ~. ~ II'··· .~. I ~ ~ ~ ~ ~. ~ , ~ ~ I I ~ i ~ ~ ~. ~ , ~ i I ~ - ..JI.. --WI ~"III!'~. ..... ....JI_.. __... _.