HomeMy WebLinkAbout940454
AFFIDAVIT FOR COLLECTION AND DISTRIBUTION OF
DECEDENT'S PERSONAL PROPERTY
PURSUANT TO WYO, STAT, ANN. § 2-1-201 (LEXlS NEXlS 2001)
STATE OF WYOMING )
) ss.
COUNTY OF NATRONA )
000697
I, MICHAEL HILLSTEAD, being of lawful age, having been first duly sworn, depose
and state as follows:
1. This affidavit is made in accordance with the provisions of WYO. STAT. ANN. §
2-1-201 (LEXIS NEXIS 2007), and the Certificate of Death hereunto annexed, and by this reference
made a part of this affidavit, is a copy of the official death certificate of the decedent, JOHN FRED
HILLSTEAD, certified to by the public authority in which such original death certificate is a matter of
record.
2. On the 2nd day of January, 2007, JOHN FRED HILLSTEAD died in
Bonneville County, State of Idaho, and at the time of death was a legal resident of Lincoln County,
State of Wyoming.
3. The value of the entire estate of JOHN FRED HILLSTEAD, wherever
located, less liens and encumbrances, does not exceed $150,000.00.
4. More than thirty (30) days have elapsed since the death of JOHN FRED
HILLSTEAD.
5. No application for appointment of a personal representative is pending or has
been granted in any jurisdiction.
6. JOHN FRED HILLSTEAD was survived by one child listed below:
Michael Hillstead
7. There are no other persons, other than the persons named in paragraph 6, who
have a right to succeed to the property of JOHN FRED HILLSTEAD under probate proceedings of
the State of Wyoming.
8. JOHN FRED HILLSTEAD was the sole owner of the following described
personal property:
2001 GMC Pickup, VIN #2GTEK69U911242574
9. WYO. STAT. ANN. § 2-1-201 (c) (LEXIS NEXIS 2007) provides:
"When filed with the county clerk and a certified copy is presented to a
party with custody of assets the affidavit shall be honored and have the
same effects as provided for in subsections (a), (b) and (d) of this
section and WYO. STAT. ANN. § 2-1-202 (LEXIS NEXIS 2001). The
county clerk of the county in which any vehicle is registered shall
transfer title of the vehicle from the decedent to the distributee or
distributees upon presentation of an affidavit as provided in subsection
(a) of this section."
RECEIVED 7/11/2008 at 11 :38 AM
RECEIVING # 940454
BOOK: 699 PAGE: 697
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
ú00698
Therefore, the affiant hereby instructs the county clerk of the county in which any
vehicle described in Paragraph 8 above to transfer the title of such vehicle &om the decedent to
MICHAEL HILLSTEAD.
12. WYO. STAT. ANN. § 2-1-202 (LEXIS NEXIS 2001) provides:
"The person paying, delivering, transferring or issuing personal
property or the evidence thereof pursuant to affidavit is discharged and
released to the same extent as if he dealt with a personal representative
of the decedent. He is not required to see to the application of the
personal property or evidence thereof or to inquire into the truth of
any statement in the affidavit. If any person to whom an affidavit is
delivered refuses to pay, deliver, transfer or issue any personal property
or evidence thereof, it may be recovered or its payment, delivery,
transfer or issuance compelled upon proof of right in an action by or
on behalf of the persons entitled thereto. Any person to whom
payment, delivery, transfer or issuance is made is answerable and
accountable to a personal representative of the estate or to any other
person having a superior right."
Therefore, the affiant hereby instructs anyone having possession of any tangible
personal property of the decedent to also deliver that property to MICHAEL HILLSTEAD.
Any person or entity distributing property pursuant to this Affidavit may rely on the
receipt attached hereto as evidence of its payment, delivery, transfer or issuance in full satisfaction of its
duties under WYO. STAT. ANN. § 2-1-201 (LEXIS NEXIS 2001).
, "1") JVJ
DATED this LL day of June, 20<W.
FURTHER YOUR AFFIANT SA YETH NAUGHT.
AFFIANT:
~~~
MICHAEL HILLSTEAD
The foregoing instrument was subscribed and sworn before me by MICHAEL
HILLSTEAD, this ~ day of \}CAAJe , 20~
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STATE OF IDAHO
IDAHO DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF HEALTH POLlCYf.ND VITAL STATISTICS
000699
DATE FILED BY STATE REGISTRAR:
Slale Or Idaho
CERTIFICATE OF DEATH
CD 1.0
STATE FILE NO.
... 1. DECEDENT'S LEGAL NAME (Indude AKA'S,,1f anyJ (First Middle. LIS!. Sumx)
RllY NUMBER
5. DATE OF BIRTH IMoIOøyIYr)
10, 1939)
orelgn Country)
67 IVe.,,) i September
.s ra. RESIDENCE· STATE OR FOREIGN COUNTRY Tb. COUNTY
..
" I
~ Wyoming
~ rd. STREET AND NUMBER
~ 489 Jackson Street
z;~ I. MARITAL STATUS AT TIMÊ OF DEATH
~ ~ 0 Married 0 Married, l:ul "'""rflrilled R WtdOWP.d 0 Divorced 0 Never "",,rTll'!d
u- , '_0'
J:: .!l 10, EVER IN U.S. 1h. FATHER'S NAME (First, Middle.lasl. SufOx)
0:: ü: ARMED .
o -g 'ORCU? George Noah Hills tead
~; Ja YIIS 121. MOTHER'S MAIDEN NAME IFlrsl. Middle. Lasl, SIJllix)
lii ON. Jean Taggart
~ 13.. INFORMANT'S NAME (Type or prlMI)
..
~ LaVon Lancaster
8 * 14. METHOD OF DISPOSITION
3. Burtal 0 Crerrollon
o OonllllOl) - 0 EnlootJmenl
U Rem,v,1 'rom Idaho
o Olher (Specl
* 11.. SIG VR
. '
7a. INSIDE CITY
LIMITS?
1Ð VIIS 0 No
OIJ"kl1<1Wn
11b. BIRTHPLACE (SllIle. Terrllory, or ForeIgn Counlry)
Utah
12b. BIRTHPLACE IStale. Terrilory, or Forefgn Country)
1:1b, RELATIONSHIP TO DEcEDENT
lale, Zip Code)
'sister
15. PLACE OF DISPOSITION (Name and address of cemelery.
cremelOf)', other placeJ .
I\fton Cemetery
Afton, Wyoming
ERSON ACTING AS SUCH
.. l1b. LICENSE NUMBER (or licensee)
M - 676
PLACE OF DEATH 19·22
* "..IF DEATH OCCURRED IN A HOSPITAL: 1* "b, IF DEATH OCCURRED SOMEWHERE 0 HER THAN A HOSPITAL:
1M tnp&1I'nl ,0 ERIOulpøllenl 30 OQA 140 Hospice 'actnly ,0 Nursing homeJt.ang lerm C8r. 'aelltly ,0 Decedenl's homo ,0 Qlher (Spedfy)
'" .to. FACILITY NAME (If l!2I '.dNly. give slreel.nd number) * 21. CITY, TOWN, OR LOCATION OF DEATH, AND ZIP CODE * 22. COUNTY OF DEATH
Eastern Idaho Regional
1'. WAS CORONER CONTACTED?
DVes RNo
Idaho Falls 83404 Bonneville
25. DATE PRONOUNCED DEAD (MOIDayIYrl (Spell monlh) 21. TIME PRONQUNCED DEAD
2
2007
I""" January 2, 2007 I
27, CAUSE OF DEATH ,
PART I, Enler Ih, ~l .. disease!, Infurles, or c()('t1JllcaUons - U1øt dlfec1ly caused Ihe dealh. DO NOT enler lermlna'l events such 85 cardl8C
8rt8SI. resplralory Irt8Sl, or·venlrlctJlar "brlll.llon wllhoul showing the eUoIogy. DO NOT A8BREVIATE. Enler only one caUIII on a line:
'Q. eo;,. Q \ ~'" \-0 f.k\. ~ \...vu:L
DUE TO f~'M . eorI'eqIJl:nCI ofJ:-.J r
b, c..o f 0
1316
I Apptoxlmale 'nletval:
I OO5ello De:,th
: ~ f>1 GI"r\.{.ú".
I ~ ~",('j
IMMEDIATE Cj\USE (~'nll
dls~ase or condlllon -+
tfS¡fUng In dealh)
Sequenllllty nsl condlllons,
If.ny. leedlng 10 Ihe ClUse
IISled on IIn.... Enler Ihe
.s UNDEA.l YINb CAUSE
(Q lAST (disuse Of Infury/
~ ~~:~~~::~dd~~~h~venls I'd.
.. ~ PART II. nler olher slanIßC'.4nl condlUons conlrlbuUno 10 dealh bul nol resulllng In lhe underlying cause Qlven In Patti
~Æ r-e..\I\Cl.1 (\,.1/\0
u.. N 29. DID TOBACCO USE
t=,... CONTRIBUTETODEATH7
ffi ~....erf'es 0 Probably
U~
.s 0 Nt! 0 tlr1.....O\·.'t1
~ 37. DATe OF INJURY (MoIDaylYr,
E (Spell manlh)
8
DUE TO IOf III . to"~I!qUIItCe orJ:
c,
DUE TO lor "" tonnquenCI DI):
30. IF FEMALE (Aged 10.5<11:
o No! pl'"egnanl wllhln past year
o Pregn.nl.1 lime of deBth
o Nol pregnant bul pregnanl
,...~I"··, ~ l t!Jly. of d.!llh
o Nol pregnant. but pregn.nl -43 days
to 1 yeer before dealh
o Unknown If pregnllnl wllhl" Ihe pul
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281. WAS AN AUTOPSY ;28b. WERE AUTOPSV FINDINGS
PERFORMED? r AVAILABLE TO COMPLETE
: THE CAUSE OF DEATH?
DVes .&3"110 lOVes DNo
31. MANNER OF DEATH
~Iural 0 Homicide
o Accldenl 0 Pending Inveillgølloo
[1 Suldd~ 0 Couto ñot be tI~ll!rmll1ed
35. INJURY AT WORK7
33. TIME OF INJURY
34. PLACE OF INJURY (Decedenl's hOl'T'Ml, 'arm, slreel, constl\lcllon slle,
nur~ng home. re!llaunml, foresl, etc.)
(24t1r)
DYes
31. lOCATION OF INJURY:
Slale
CllyfTown 0( Counly
Zip Code
Slreellnd NUlTÒer or locallon Apar1menl N.urriler
31. DESCRIBE HOW INJURY OCCURRED. IF TRANSPORTATION INJURY. STATE THE TYPE(S) OF VEHICLEIS) INVOLVED (Aulomoblle. pickup. moIon:yde. ,bicycle. etc.
SPECIFY WHICH VEHICLE DECEDENT OCCUPIED. If applicable
TRANSPORTATION ,38a. WAS DECEDENT: OrIverlOperalor Passenger 38b. WHA SAFETY DEVlCEIS, DID DECEDENT USEI PLOY?
INJURY ONLY I 0 Pedeslr1an 0 Other S eclf I 0 Seal bell 0 Child lately seal 0 Helmel 0 Air bIg 0 None 0 UnknOWfl
3Ia. CERTIFIER (Check only one, based on official cap.cllr lor Ihls cer1mcalel J . IC 9E U BE
R PHYSICIAN· To Ihe besl of my knowledge, dealh occurred 811he lime, dale, and place, end due 10 Ihe lL~ cause(sVmanner staled. ¡t1 l( 3 c¡ L{
o CORONER· On Ihe basis ot eXllmln8110n andlor InveslIgallon. In my opinion. death oa:urred øllhe lime, dale, and place, and due 10 the 39 A.TE SIGNEO
cau.e!., ,nd ""nne' .lated, / . .A" .. ( Q.I) I c, 0" I f~~
SIvnalur.,"dTlU.ofC.rtlflllrÞ- ~l/Ir-¡~ MM 00
* Jld. HAME. ADDRESS. AND ZIP CODE OF CERTIFIER (Type Of print)
William E. Armour, M.D.; 2001 South Woodruff Ave; Idaho Falls, Idaho 83404
<lOa. ;~~~::~:r~~~~~~~: :~~~:'!~~e~:;tE.CESSARY: The ~on~,r'~sI~~IW.~_I~ IN. 118m supersedes t~al of the physfdan, -10b. DATE SIGNED
I f
MMDD~
41b. DATE SIG~Ep
LI..!:1:_L.2.iXi:J.
MM DO YY't'Y
This Is a true and correcl'reproductlon of the document officially reglstared and plac~d
on file with the IDAHO BUREAU OF HEALTH POLICY AND VITAL' STATISTICS.
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DATE ISSUE~J1 rLll(]~ r~ )..j I 7..ti)[
This copy not v';1Id unless prep~re on· engraved border
displaying state~eal..and, signature,. of,. the Registrar,..
~~~
JANE S. SMITH
STATE REGISTRAR
124".)
ON.
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