HomeMy WebLinkAbout933860
0'00015
AFFIDAVIT OF DISTIBUTEE FOR TRANSFER OF WYOMING CERTIFICATE
OF TITLE AND WYOMING LIVESTOCK BRAND
STATE OF WYOMING )
)SS
COUNTY OF LINCOLN )
We, Gloria Johnson and Rick Johnson, the surviving spouse and surviving son
being ftrst duly sworn and upon our oath, state the following:
1. That the decedent, Clint W. Johnson, died on the 9th day of September, 2007.
A certified copy of the death certificate is attached to this affidavit and made a part hereof
as Exhibit "A'" '
,
2. That the names of the Distributees entitled to payment or deliverance of the
decedent's property are:
a. Gloria Johnson, surviving spouse;
b. Tamira Wolfley, adult daughter;
c. Cindy Coziah, an adult daughter;
d. Rick Johnson, an adult son;
e. Christy Stevens, an adult daughter; and
f. Tara Frome, an adult daughter.
3. That the value of the entire estate of the decedent, wherever located, less liens
and encumbrances, does not exceed seventy thousand ($70,000) dollars;
death;
4. That more than thirty (30) days have lapsed since the date of the decedent's
5. That no application for appointment of a personal representative is pending or
has been granted in any jurisdiction;
6. That the above-named Distributees are entitled to payment or delivery of the
decedent's property and there are not other distributes of the decedent having a right to
succeed to the property under pro bate proceedings;
7. That the undersigned request that the following described property be
transferred to Gloria Johnson, the surviving spouse, and Rick Johnson, the adult son:
a. A 1991 Chero stock trailer, VIN lC91BEF2XMlO08203,the title of
which is attached and made a part hereof as Exhibit "B";
b. A 1994 GMC Pickup, VIN 1 GTFK29K6RE560318, the title of which
is attached and made a part hereof as Exhibit "C" ; and
c. There is also the matter of a Wyoming Livestock Brand that is in the
name of Clint W. Johnson, the decedent in this affidavit, and Ervon
Charles Johnson, who is also deceased, as shown by his certified death
certificate, attached and made a part hereof as Exhbit D".
RECEIVED 10/9/2007 at 1 :47 PM
RECEIVING # 933860
BOOK: 675 PAGE: 15
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF DISTRIBUTEE FOR TRANSFER OF WYOMING CERTIFICARE OF
TITLE AND WYOMING LIVESTOCK BRAND
Johnson/Johnson
Page 1 of3
AFFIANTS SAITH NOT FURTHER.
000016
DATED this 4d day of
t2~tyM¿
,2007.
~~
-G ORIA JOHNSOJ,Sl/
fk1 ~_-
RICK JOHN~N
. ~
~~~W
TAMIRA WOLFLEY ~
GJuJf~(r(~
HRISTY S'L
SWORN TO AND SUBSCRIBED TO before me, a Notary Public ~ ap.Ji for the
above-mentioned State and County, by Gloria Johnson, personally on this ~day of
October, 2007.
WITNESS my hand and official seal.
~~0~
NOTARY PUBLIC ./,.1
My Commission Expires:~d ð) ;011
, SWORN TO AND SUBSCRIBED TO before me, a Notary pUbl~and for the
above-mentioned State and County, by Rick Johnson, personally on this "day of
October, 2007.
WITNESS my hand and official seal.
__OMMeNNES NoWy"." ~ ~. y)~
County of State of . ,~/LIuJ.-r} ~ '
Lincoln Ing NOTARY PUBLIC
My Commission ExPires:~~ ~ I /
SWORN TO AND SUBSCRIBED TO before me, a Notary Public ÜWl~ for the above-
mentioned State and County, by Tamira Wolfley, personally on this i!t1Jf¿day of
October, 2007.
WITNESS my band and official seal~
~ '>t~~
NOTARY PUBLIC "./
My Commission Expires: ~-tlv !J ~ II
AFFIDA VlT OF DISTRIBUTEE FOR TRANSFER OF WYOMING CERTIFICARE OF
TITLE AND WYOMING LIVESTOCK BRAND
Johnson/Johnson
Page 2 of3
00001.7
SWORN TO AND SUBSCRIBED TO before me, a Notary Public in and for the above-
mentioned State and County, by Cindy Coziah, personally on this lci day of October,
2007.
ON NIMMO WlNE.S N,O, tary Public
County of Stal . of
Lincoln r~J. jng
My Commission Expil1ls ~ 1/1 (
WITNESS my hand and official seal.
~Þrl~~~
NOTARY PUBLIC -IL i
My Commission Expires: ~,q/-- I bJ¿; II
SWORN TO AND SUBSCRIBED TO before me, a Notary Public in and for the above-
mentioned State and County, by Christy Stevens, personally on this ~day of
October, 2007.
WITNESS my hand and official seal~L ~ ~4:tM
HARONNIMMOWlNE.S NotaryPU~IiC NOTARY PUBLIC ~ i
County of SI Ie of Z. /.
Lincoln Wing My Commission Expires: . ~-<-- I ¿?cJ /1
My Commission Expll1ls ~
SWORN TO AND SUBSCRIBED TO before me, a Notary Pub2i ~and for the above-
mentioned State and County, by Tara Frome, personally on this ~ay of October,
2007.
WITNESS my hand and official Seal~/)
~~v)MtM
HARONNIMMOWlNES NOTARY PUBLIC .4 ~
c(,~~:'nOf My Commission Expires:V--~ll ~ II
My Commission Expires
AFFIDAVIT OF DISTRIBUTEE FOR TRANSFER OF WYOMING CERTIFICARE OF
TITLE AND WYOMING LIVESTOCK BRAND
Johnson/Johnson
Page 3 of3
. .. .'
STATE OFIDAßO'; "",.',/
IDAHO DEPARTMENT OF HEALTH ANo'WEL¡:ARE':."~;:;';..",
BURËAUOF HEALTH POLICY ANI:? VITAL S!ATiSTICS:·:,:;:;;-':"\""':;
,~'.".
.,:¡;..
SI81e of Idøho
CERTIFICATE OF DEATH
·,"··:r
,',
STATE FILE' NOI
, ,
TYPI ..
.....,.
""MANINT
lLAClt1Nl(
DO NOT un
F!l.T11JI ,...
,.'OIIo.:,.~r::u~:;,:-~,.:,:~;:~~-:,.':"~ÞI';'~~'::'~':::}::"~:::':e""1 t~1 Reg. NO:::.<
*' 1. DECEDENT'S LEGAL NAME. (Indude AKA', I( ,nyl {FI,.I. Middle. La.I, Su"lxl 2, SEX 3. SOCIAL SeCURITY NUMBER
~ Clint
ð.... ,I
...
Q
~
ð ..
64
FO"
"'lmUCTIOHI '"
""
HANDBOOK'
Idaho
A
...--............
~
~ 2860 Highway 238
if "MARr! .. 8 M
~
f
I
3b. RELA ONSHIP
o M,nfed, bul ..peralltd 0 WIdowed 0 Dlvoreed 0 NitY8r mlrrted
1 .. F AM I rlt, e. Lul, uftixl
Ervon'Charles Johnson
21, A' NAME IF1111, Idde, Lall, ufllx)
CILITY "-.1:,>5":1 .,"
I M - 676
PLA E OF OEATH (19·22)
o URRED IN A HOSPITAL: I 19b. IF DEÃTH O'ëCURREDSÕMÊWHERE OTHËR l'HÄÑ-A HOSPITAL:
,1] E'VOuIJNIllenl 3(J DOA '.0 HOlplcg rlcmty In Nursing "'omeA..ong I.rm CIIrg '8cUlty .':] Q,c@d,nl', "'ome 0 Olh., (SpecIfy)
20, FA IU AM (I om IldUly, give s"lel and number) 21, CITY, TOWN, OR LOCATION F DEATH. AND ZIP CODE
Eastern Idaho Regional
Medical Center
23. DATE OF DEA IMoIOlyIY",ISpeR monlhll,
Se tember 9 2007 '
~,. :',
22, OU TV OF DEA'OI
Bonneville
215. ·T1ME PRONOUNCED DEAD
0055
12'.')
--, ,,--
Sequenlllny n'l condIllonl, b,
II IIny. .actlng 10 lhe ceUH
bl.d on JInI I. Enlll'!he
~ UNDEALYlNQ CAUSE
LAST (dlna.. 0' '"fury
.. Ih,llnlllalld IhtJ lYenll
0 'd.
õ re.unlng In dealh)
I!.! P' T II. Enlllf
l
'" 20. OA
.... CONTFIIDUTE TO DEATH?
í
~ OVe. OProbobty
" "y~~
bu! noJ relUJllng In.the underfylng au" given In Pari 1- l'i¡j.: WAS -AN ÄUTô"PSŸ ;Zib:'wkliiÜTOPSY' jiiÑDINiJS ..
f PERFDRMED?, , ~:I~~~~~ ~~ ~~:~~
.____.....__.: [-,VI'X' . iJV" [J No
30. IF E AL lA.ged10~ l -----.-..-----.-.-----.
1..:..1 Nol pregn.nl wllhln plSI yeer n No! p,egn.nl. bul pregnlnl 43 day. 131. MANNER .OF DEATH \
J] pregnanl'.I lime 01 deelh 10 1 yelr belore de,lI, \ ~llurlll U Homlcidè
[,1 Not pregn.nl. bul prlgnlnl ::J ,Uen.~nown H pr.gnlnl wllhln Ihe pasl I' U I\ccklenl ¡.J Pøndlng InvesllOlllon.
wllhlM <42 d~y. 01 dlllh l'" Suicide .: -1 Could nol-be d, ,rmlned
33.,rIME OF INJURY 34. PLACE. OF INJU Y (Dllcedønll home.lgrm. ,lre.l. conslrucUon ,U., J5.INJURY AT WORK?
___~~lnuraln.:~"'.:.~'~'.I...,1."C) __...___~_,_.' L.' Y.. -, No
Gltyrrown or County ZIp Code
.!!)øC1O 0 Unknown
! 32. DATE OF INJUAY (MoIOaylYr
8 CSpo' '-h)
38. LOCATION OF INJUFlY;--~;ì;---
5IrftI' and Number or Loc:ellon Apllnmenl Number
u. DESCAIBE HOW INJU~Y OCCURRED, IF TRANSPORTATION INJURY, STATE THE TYPE(S) OF VEHICLE(S INVOLVED IAuIOmobIIB, pickup, moion:ycfi.-A , yele.lllc.
SPECIFY WHICH VeHICLE DeCEDENT OCCUPIED, II Ippllcabll
.-
-r:-'~FETY OEVICE(S) DID DECEDENT USE/EMPLOY?
I 0 III Be" 0 Child IIlety 11111 0 H.lm.I 0 Air beg U None 0 Unknown
3gb. LICENSE .NUMBER
" DU.TH WAI
oul TV ant!!A
mAN NATURAL
CAU8.1,
TH! COFlONI!A
MILSI
c~rn AHD
SIONTtfI
C!Rnm:ATI
W'l"J--7--
3~1::-~G72:,,4l-
MM ~ yyyy
...-...-.--
d
¡
Idaho 83404
n, l'Ob, DATE SIGNED ...' -------
,_,_,-
I "MM 00 YYVV
~'b. ?1l2li/2fXEL
MM DD yyyv
.....,,~... .,... ...............
This Is a true and correct repro~:;tlon of the document offiCiallY' registered and placed
on file with tho IDAHO BUREAU OF HEALTH POLICY AND VITAL STATISTICS.
"
DATE ISSUE~C)¿ nip J1.A bf.v'2-&,'21ff7
T' ,',- " ,
¡his copy not valid unless prepared on engraved border
displaying state seal,an?:slgnature of the Registrar.
,..,~
. .. .' .
- Co ,,". , "
~~~,,'.,.,. ,..'.
JANE S: SMITH
STATE REQISTRAR,
EXHIBIT "'A"
I
.:. r·"
000,019
'"
WYOMING
TITLE NUMBER 1" -'"'1-'''1'''
.:,_1.,)", ~c~.:j
OFFICE OF COUNTY CLERK
LINCOLN C(}(1}ITY
:EŒl;,,:U\,illRE:R,: WY
.,
FEE $9.00
DATE ISSUED 5/5/04
3290282
EXHIBIT "B"
000020
I
WYOMING
TITLE 1'1,' IMBER 12-0228637
'.,
OFFICE OF COUNTY CLERK
LINCOLN COUN1'Y
KEMMBRBR,. WY
FEE. $9.00
DATE ISSUED 8/1212005
i,ÇJ;J3TIFJCATE ,QEIr[LE~
.~.~ifl{fi~¡}¡fr!è~j¡;{:~r~~~
S~LLER ,. .,,', , " t '
MICHABL'F. &
.L. .~:!.~~~~~ ~~1~~!~~~~",
JOHNSON. CLINT
2860 HWY 238.
AUBURN WY 831 Ü":
", ' ,'"' ....' '.
, '
VEHICLE BRAND
- ,
. !~.
.. '
!':,ì
t
~
,".,;
,
'"
I
!
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'IN WrrNESS WHEREOF, I hav~ hereunto caused this Certlfi·
'cateto be signed and the official seal' ot,:U'Ii\Jllioff.ip',e to be
placed. thereon. ...., " . ',:/~~:\.~.....::....~:;~;:>,.~
Jeanne Wag~eI"/' n 0 '\ .,~, OJ,
C µnty CI
I, '$.
MV·301 (01/04)
3291654
EXHIBIT "c"
I
000021
\
¡Þ~
TYPE
OR......T
IN
PERMf\NENT
BLI'C.
INK
FOR
INSTRUCTIONS
SEE
HANOBOOK
LOCAL FilE NUMBER
1 DECEDENT ·NAME FIRST
Ervon
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
MIDDLE
Charles
LAST
JOHNSON
2. SEX
Male
STATE FilE NUMBER
3. DATE OF DEATH IMo., Diy, rr.}
March 5, 1994
... SOCIAL SECUmTY NUMBER
5c. UN I DAY
Mlnulaa
6. DATE OF BIRTH tMø.. o.y, Yr.'
10 PLACE OF DEATH (ChecA only one)
~ 0 'np.II,"' 0 ERI(Mo.II.n, 0 DDA ~, 0 N,,,'''' Hom. IXAnld.nc. 0011'" (Specl/y)
lb. FACIUTY NAME m no( Ins"CUlfon, gllffJ s'nref .nd IIUITIÞtw J 1c. CITY, TOWN. OR LOCATION OF DEATH
Se tember 30 1920
2682 State Hi hwa
8. STATE OF 8JRTH (If not In U.S.A., rnm. country}
238
9. MARRIED. NEVER MARRIED.
WIDOWED, DIVORCED (Sp""y)
Auburn
10. SURVMNQ SPOUSE,II ~(ft. 11'" møidlln tlllmel
. ..
Married Eva Fo
121. USUAL OCCUMTION (Give "Ind Of worlf darN dllfng nlOs'
of MVrlI;kfU' Nt., ewrn " ,,,,/f.d I
13b. COUNTY
Far e
13c. CITY, TOWN OR lOCATION
Lincoln Auburn
14, WAS DECEDENT OF HISPANIC ORIGIN?
ISpecllV no or Y81 - If vel, !IIpeclry
CUbln" Meltlcln, Puerlo Ricin, Elc.
'e. DECEDENT'S fOllCArroN
(s".øty on/'( htf1'-- f f'ade ~ed
EIIIIMnl..,/8econdary 10-12 CoIleg. I' -4 or &+)
Ye.D (Speclly}
Middle llll
8
Flrll
Mid""
MBlden Surnune
Arthur
191. INFORMANT-NAME (T,pl! or Prlnl}
William
Johnson
Crook
19b. RELATIONSHIP TO DECEDENT
Clint Johnson
Son
l.a. MAILING ADDRESS
STREET OR R.F.O. NUMBER
ZIP COOl!
Rt
2Dd. lOCATION
CITY OR TOWN
STATE
Wyoming
P.M
~
it
!a;
Jã
lJi!i
..0
23.. Ihe tJe;... 01 ...mI"lIlIo" . 01' mvesl 110". " "'Y up
II the Uma, dll. end place Ind dull 10 11111 "US.CI' e'lIllId.
(Sfgtw,UI'fI Ind ""111 ....
2ab. DATE SIGNED (Mo., Day, Yr.J
Wyoming
delllh occun.
l3c. HOUR OF DEAn..
23d. PRONOUNCED DEAD {Mo., Duy, Vr.J
M
23.. PRONOUNCED DEAD (Hour
M
110 Hos ital Lane;
83110
ApproMIm::J11I
Ilntllrval Delwe8n
IOnlol And Death.
,
: n..o
b,
\b~
.t
SeQUentl.lllfy lIal condillons,
If IIny,l..dlng 10 Immedlala
CIIIU". Entor UNDERLYING
CAUSE IDi....o or Injurv
I~I InUl8lod evenl.
,..ulllng In d..'h LAST
DUE TO lOR AS A CONSeQUENCE OF ;
.
PART II. OTHER SIGNIFICANT GONOITIONS-Condlllon. conlrlbuling 10 dealh bul 1'101 relllted 10 CIUI, \lmn in PART I.
o Ptmðlng
11M!.lIgatlon
.10., DATE OF INJURY
(Monlh, D.y, Va..
3Ob. TIME OF
INJURY
JOe. INJURY AT WOnK1
(Specify ...s or no}
No
~O:.~
,,~
~~
:.!9 MANNER OF DEATII
VA 2-89, .
2/91 151>31
o Could 1'101 be
Datofmined
M
30e. PlACE OF INJURY-AI home, I.rm. .lrul, Inclory,
officII building. etc. (Specify}
301. I.OCATlON ISlro~H 0111:1 Numbcr Of Rural Rout.. Numbø" Clly or T,""n, Slllel
.._ -, .', .. L;~
,,,,,::( \.. U r \() S \' t.
f;*;':~':'~""':<~"':
~'\""':"SEA,L :".
"f;->. :", ...j :
~,v~~~~~;:.<:.: _ C..."" ;
".\ ,,//.........\(".
,~". Y(1f 1 \ ..
, ':: ~;,~. '~. ~YI-
THIS IS TO CERTIFY that this reproduction is a true
copy of a record on fi 1 e in Wyomi ng Vi ta 1 Records
Services, Cheyenne, Wyoming.
This copy is not valid
sea 1 and the si gnature
Registrar is in red.
unless
of
it
the
bears a
Deputy
raised
State
Date Is'sued
M¡¡rC'h 21. 1994
~~~a?!r:.~
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EXHIBIT "D"