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Home My WebLink About932478 RECEIVED 8/27/2007 at 10:57 AM RECEIVING # 932478 BOOK: 670 PAGE: 67 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, wr AFFIDAVIT 000067 STATE OF CALIFORNIA ) ) ss. COUNTY OF ORANGE ) COMES NOW, the undersigned, and deposes and says: 1. My name is Howard E. Hamann. I am of legal age and reside at 7 Sequoia Drive, Aliso Viejo, California 92656. 2. That Shirley E. Hamann died on August 19,2006. 3. That I was named as successor trustee ofthe Hamann Family Revocable Trust dated the 31 5t day of July, 1995, upon the death of Shirley E. Hamann. 4. That attached hereto as Exhibit "A" is a certified copy of her death certificate. 5. That I have served as successor trustee ofthe Hamann Family Revocable Trust since August 19, 2006, and continue to serve in that capacity. 6 That this Affidavit is made pursuant to W. S. §34-2-123 (LEXIS 2007). FURTHER AFFIANT SA YETH NOT. ~ GOWARD E. HAMAÑN SUBSCRIBED and sworn to before me this ~dayof y ,2007, by HOWARD E. HAMANN. WITNESS my hand and OffiC~ Public My commission expires: ,tflf~ el. Zlt!r j~~-----~~---f . KI PAE .... Commission # 1564555 ~ . Notary Public - California f Orange County - My Comm. Expires Mar 26, 2009 COUNTY OF ORANGE HEALTH CARE AGENCY 1200 N. MAIN STREET, SUITE 100-A SANTA ANA, CA 92701 i AKA. AlSO KNOWN AS-1neUM U AKA FIRST, MIDDLE. L.ASn i i ~ 3 2006 30 0' I I 0 9 2 AL ~' ! ~ ~ I ~.. ~ ~ ~ I I I I I I I I STATE FILE NUMBER 1. NAMEOf' OECEDENT~ FIA8T (QIv«i SHIRLEY LOCAl FIEOISTftAnoN NUM8l:R 10. soc:tAL SECURITY NUMBER WHITE 17. USUAl OCCUPA'ßDN.- '1YP- of.-ll lor ~I cf.... DO NOT USE REnRED HOMEMAKER 18. KINO Of BUSINESS OR IØ.ISTRV II.g., QIOC*Y lien, raed COfIItNctIon. MIØ/OymInt.gency, *~ 1'. veAA81N0CCIJPA110N OWN HOME 49 20. ŒCEDENr8 RESIDENCE tSItHt .00 ,...,... III' aoç.UOn ~ I ~ ~ I "~ I ~ j I ¡ I I I I S 7 SEQUOIA DR I" ".CITY m ALl SO VIEJO = ~ II. INFORMANT'S NAME, RE\.ATIONSHIP ~¡ HOWARD HAMANN - SON 28. NAME: Of SURVIVING SPOUSE/SADP"-FlRST ~~ - ~ I 31.NAMEOFFA1}IE~ENT-fJRST I Iii James i i 35. NAME OF MOTHERIPMENT-F1RBT ~ WinI)ifred H. DISPOSITION MTE.nwnIddIccn' -40. PI.ACE OF FINAL DISPOSITION ~ ~ 08/23/2006 I! 4'. TYPE OF DlSPOSmONS :;I g CR/RES 15 4... NAME Of FUNERAl ESTABUSHMEHT ~ McCORMICK & SON 22. cotJN1VlPAO\I\NCE ORANGE 28.MIODI.£ 32."""'" 33. lAST Evans 31. lAST (BIR1'H NAME) Brundage 34. BIRTH STATE 1M'DOlE 31. BIA1HSTATE WY RESIDENCE: HOWARD HAMANN 7 SEQUOIA DR ALl SO VIEJO CA 92656 ORANGE 3 PURSUIT r...Þ¡ 'Óšï2Ït2Õô6 t· 42. SIGNATURE OF EMBALMER 43. LICENSE NUMBER 101. PlACE OF DEATH ~~ COVINGTON 1().4. COUNTY 105. FACIUTV ADDRESS OR l 100. CITY ALl SO VIEJO 107. CAUSE OF DEATH EnI., IhI dIIIn 01-', ..- diMuea. ~ orem1JbIionl-··1hIt chcdy c...-d dNIh. 00 NOT «Iter IIIIT\'NI MnII aucn ..~..-t, .......ory......lII'~ .....1Io1~houIlhcIwW1g 1hI1I~. 00 NOT AB8RE'MTE. TmtInllmlBtlwttn 101.DEAnAEPORJE)TOCOIOØ'I I /1.rx;ltndo.Ø' D~_IXJ t«) : ¡-mon :181! too. ENOPSY PEFIFOAME07 D YES Ii] .., 110. AUTOPSY PERFOflMED1 DYES L.., 111.USEOIN~Þ.U8E1 DYES D'" IMMEDIATE CAUSE Vol ::~~-+ Metastatic Endometrial Cancer "- IBI _.... j!; oondIUonI.ø.-.v, m ~~!iZ ~ ~ CAUSE fdII.... III' W ~:-;.. -m. ~ 5 redng In dAlh) LAST ¡~ ¡lOT) 112. OTHER SIGNfK:ANT CONDmONS CONTRIBUTING TO DEAni BUT NOT AE6UlllNG IN THE lJM)ERLYINß CAUSE GIVEN IN 107 NONE 113. WAS OPØIATION PERFORMED FOR ANY CONDITION IN ITEM 107 OR 1121 II )1M. lilt ~ 01 operation IfId elltl.) :;. I,{} u n NO 114.ICEFnFYTHAt'TO THE em OF IliI<NOWl..IDOE DEATH 0CCl.IIAE1J 111M HOI.J\~1[,NlDPI.ACE mTEDFROMTHECMJ5E5 swm. o.c.... A1terd1c18/Ia o.:.dInI LaI SIIn MvI' Vol rnmIddlçqoy . (B) mmIddfcayy 10/03/2005 ¡ 08/17/2006 S. 111.1 ŒRm THAT IN Ili 0PtI0H DEATH 0CClØIE0 AT tHE HOI.J\ OOE, Nt) PlACE STATED FADM M CAUSES STAYED. MAtHRŒDEATH D NeI~ 0 AcckIIntD tbYt:IdI D SUddI 0 =ta. D~-= i 123. PlACE Of' INJURV(e.g.. tIorM, ~..~ woodMt .....1(:.) .. !1 i § u 12', DeSCRIBE HOW INJURY OCCURRED (Event. which reNt.:! In Irpy 125. LOCATION OF INJURY (StnIe1 and number. or IocIIIIon, IfJd city, and ~ 12e. SIGNATURE OF CORONER DEPUTY CORONER 121. DATE ,mmJddIccyy ~ STATE REGISTRAR STATE OF CALIFORNIA COUNTY OF ORANGE CERTIFIED COpy OF VITAL RECOROc?!(ð ~2~2i:mllll'1I11ll11ll1I1I11I11ll111'1"1II11II1111ll111"1 '",",x,.":..;~:.,<t'it1<i."",,~,,,,",-r. 0 0 1 9 6 4 3 3 0 * } SS DATE ISSUED This is a true and exact reproduction of the document officially registered and placed on fils in the office of the VITAL RECORDS SECTION, ORANGE COUNTY HEALTH CARE AGENCY. I~~J lM..~ HILDY MEYERS, M.D. INTERIM HEALTH OFFICER ORANGE COUNTY. ·CALlFORNIA This copy not valid unless prepared on engraved border displaying seal and signature of Registrar.