HomeMy WebLinkAbout937139
STATE OF c. <.~ \ ~.çv \ "I.C~
AFFIDAVIT OF HEIRSHIP OF
k~(t..(L/..-1 R Ll 'S.Sr>J I}1þ.(L--L~I'd2
I Deceased
COUNTY OF
:::c ÝÎ l' I')
SS.
OOû6B2
H1 '" ~rL...\.k I; \ <.\. ,~' ~\,~ f' j. of lawful age, being first duly sworn, on oath deposes and says:
That affiant was personally and well acquainted with the above named decedent during the latter's lifetime, having known deceased for
S"'I
years,
Decedent died at is\.,- \.v) P" -.tn Y D County, State of Ca- \ \.-+0 r ('\I..c:~
On or about the 3 \ day of O(:"L¡ ~"'" .1 ,20 <:" , being ~ I years of age, and a resident of
Ô .~ ~"" 0 r~ \ c.",~ \ L-+cÇ,,- l. 0--- at the time of death.
That the following statements and answers to the following questions are based upon the personal knowledge of affiant and are true and
correct:
1. Did decedent leave a will? IV 0 If so, has the wiil be admitted to probate __: Give name of County and State in which such proceedings
are pending, and name and address of executor.
(If decedent left a will, please attach a certified copy of same, together with a copy of the order of court admitting it to probate, and letters testamentary.)
2. If decedent left no will, have administration proceedings been started? f\/ 0
said administration proceedings are pending and name and address of administrator,
If so, give the name of the county and state in which
3. Have ancillary probate proceedings been had on decedent's estate?
If so, when? IV C Where?
4. If no administration proceedings have been started, are there any plans to have the estate administrated? A../D
5. Did decedent leave, any unpaid taxes, including federal estate or state inheritance taxes or other debts? IV 0
possible, the amount of such taxes or other debts, to whom owing, and whether they have since been paid
If so, give as nearly as
6. Was decedent surety on any bond or guarantor cJ any other person's Indebledness at lime of death? #...l Q
principal debtor, amount, etc.
If so, give details as to
7. Were there any suits pending or judgments rendered against decedent at time of death?
amount involved and parties
Uo
. If so, state briefly the nature,
8. Marital Status of Decedent at Time of Death (Married, Single, Divorced, Widow, Widower) yY\¡LI.--tz...V2..C·<LIl)
9. If decedent was ever married, give the following information for each marriage: (List names In order of marriage)
Name of Spouse Date of Marriage Living/Dead Divorced Date of Death Was there a property settlement?
r:. \ 6-' t"P./ {'(\ 4<.1..-- '-<i'f~ I II I.? II '14Q . l...j("'9 or Divorce If "Yes"-attach copy.
I .,
10. If decedent had any children by any spouse, or adopted any children, give the following information,:
Name of Chiid Date of Address Living/Dead Date of Death By Which Spouse
Birth q -S~/j -
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RECEIVED 2/25/2008 at 1 0:50 AM
FORM 540
RECEIVING # 937139
BOOK: 687 PAGE: 682
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
/
11. If a deceased child left descendents, give the following information:
000683
Name of Child Date of Address Living/Dead Date of Deatil
Birth
Name of deceased child
Name of deceased child
12. If decedent left no children or descendents of deceased children, then please furnish the following information:
a. Give names of parents of decedent:
Name
Address
Living/Dead
Date of Death
Father
7
'7
b. Give names of brothers and sisters of decedent:
Name Relation
. tV' + (VI t>-2-lc;'-("\. J
~",'
r
1) ,,' ¡v\-\-
é ('1.. o(...J
Living/Dead
GAJ ,'1'1.. -
Date of Death
Address
c. Give names of children of deceased brother or sister,
Name of Child
Child of
Date of birth
Address
Living/Dead
13. If decedent left no heirs covered by Item 12 above, then attach a full and complete affidavit of heirship of said decedent In narrative form.
14. Give location or description of homestead of decedent, as of date of death Lv "I iJ yYì.(.. ·f\...01
I I
15. As to each tract of land or interest in land owned by the decedent at the time of his death which concerns this company, give the following
information which will be used primarily for the purpose of determining whether property was separate or community: (If space provided is
insufficient attach exhibit ivin same Information as to each tract.
Description Date From Whom?
acquired
\
\ q "l·O~
G~o
If acquired by Purchase, were
funds used those of decedent
only or community property
funds with souse?
16. Here briefly state facts and circumstances (such as being a relative, a close friend, or attorney or agent for, decedent) which will show basis and
source of information given above. 1". . 1_;+.. .
_.cl ,,^ c...~GJ 0; I I:.. (z..
Subscribed and sworn to before me this
My commission expires
day of
G.k~
~ UQ'VN/7 C.
,20 ~
/,/,
.......-
Notal)/-Pt16lic
SUPPORTING AFFIDAVIT ///
//
Ov~~ÇJ.b (~'Q
Affiant
( 'l:L 'L'" V.lL.(c1~l'e""
Address
Ý.h y (.
STATE OF
)
)
SS,
COUNTY OF
That
That
of lawful age, being first dul
was personally and well qualnted with
has read the above affidavit
Subscribed and sworn to before me this
during . lifetime;
and that the facts stated therein are true and correct.
day of
Affiant
,20
My oommlssloo ."/"
Notary Public
FORM 540
CALIFORNIA JURAT WITH AFFIANT STATEMENT
.
ûOOGS4
o See Attached Document (Notary to cross out lines 1-6 below)
o See Statement Below (Lines 1-5 to be completed only by document signer[s], not Notary)
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6
Signature of Document Signer No. 1
Signature of Document Signer No.2 (If any)
State of California
County of _l.~ ~ee~
Subscribed and sworn to (or affirmed) before me on this
\'t;~ day of JGtM.iI.M1JVV\ ,200<0 . by
Date MontO Year
(1) -Äv\If\(-Hú €\~VV r~..~~O ,
Name of Signer r-
~ YESENIA RWALCABA
- ~'" COmmission # 1512774
i ...e: Notary Public. California ~
: Los Angeles County
My Comm. Expires Oct 9, 2008
proved to me on the basis of satisfactory evidence
to be the person who appeared before me (,) (,)
(and
(2)
~
Name of Signer
Signature
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.
Further Description of Any Attached Document
RIGHTTHUMBPRINT
OF SIGNER #1
RIGHT THUMBPRINT
OF SIGNER #2
Top of thumb here
Top of thumb here
Document Date:
~Vlt-
\-(~~O~'
Number of Pages:
Title or Type of Document:
Slgner(s) Other Than Named Above:
~
.__:-------.-.-.-.-.~.~.
11:12007 National Notary Association' 9350 De Soto Ave., P.O. Box 2402 . Chatsworth, CA 91313-2402' www.NatlonaINotary.org Item #5910 Reorder: Call Tol~Free 1-800-876-6827
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*0000J.6867*
CERTIFIED COPY OF VITAL RECORDS
STATE .OF CALIFORNIA}
COUNTY OF INYO ss DATE ISSUED
This Is a true and exact reproduction of the document officially reglslered and placed
on file in the office of the INYO COUNTY HEALTH AND HUMAN SERVICES.
This e(ipy nol vnlid unless prepared on engroved Þorder displaying rai,ed ,eal and signature of Counl)' Henlth ·Officer.