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AFFIDAVIT FOR DISTRIBUTION BY AFFIDAVIT AND SUMMARY
PROCEDURE PURSUANT TO WYOMING STATUTE § 2-1-201
THE STATE OF WYOMING
COUNTY OF Ll (\C () \ h
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000871. - .4
AFFIDAVIT OF Ç>Qme.Úx_ ~ V\.Stl!~''f.r--.Jqn~ of person signing affidavit)
Name of Deceased Person: _~ Cl~ u'f.:..- /-fu _ VI Stlker ~
~ Y\ V\ ~ t-kt,-Y\.SQl¿-e ~/"
I, P Qh"\~kL, ~JV\SQ~'tr..j,~~i~first duly sworn upon my oath, deposes
aind states as follows: ' P U I... A'
~ - rr"-I'\S<1.¡u:.-- ~
1. That JY\o.; ~ L~..~j-\tl/\~k'f'(-(name of deceased) died on the date of
(ç 1;;-1 J f) f ~ . Ll.{nY\ P HClJ'1&tter dhA- 'Ie¡ 107
I I
2. That I am the, dO.1Á ~ k:t Å ~ (relationship to deceased) of
I ,~ ,Uk- ~~¡¿~~(nameofdeceased).
T L--"{V\\f\. P. t-tu.-'Y'\..Sct t<..e r-
3. That the value of the estate, wherever located, less liens and encumbrances, of
t.
(th~ deceas.ed) does not exceed $150,000.
«
'f L..'i n n p, '~~'€-r
4. That thirty (30) days have elapsed since the death <?f
(name of deceased). ~
fY\.C(~ Ufe~ ~¡-
L( Y) '" f\ ·l·+.vv,3Q {é.. 'f í
5. That no application for appointment of a personal representative is pending or
has been granted in any jurisdiction concerning Q. L
(name of the deceased). L'1 n Y) ? '~Y\3ClJ>eí
\
(~
6.
ntitled to payment or delivery of the
ame of the deceased) are as
Name of Distributee
Relationship to Deceased
~a yY\,<,JC\ t-\-Lt,Vl~~ r::0oY\es
d,Q, u. 9lt-e r
( *U5~e.- )
7· The above listed distributees are entitled to the payment and delivery of any and
all personal property including accounts held with any and all financial
institutions.
8. That pursuant to Wyoming Statute § 2-1-201, this affidavit has been filed with the
County Clerk, for and in the County of Lincoln, State of Wyoming.
Page 1 of2
RECEIVED 7/28/2008 at 12:31 PM
RECEIVING # 940835
BOOK: 700 PAGE: 871
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
(-00872
.... ()".,
4-
~
9· That pursuant to this affidavit and W.S. § 2-1-201, that the business and/or
financia)..¡nstitution o~ '<>ÍlJ!. ~, ~¡J;..¡..js hereby directed to
payto~¥)'\.'e- \Q. _~"':>e( ~(\ICH~ (name of
distribute(s) to receive payment) any and all accounts held in the name of
~ l~ ~(.,~~r(name of deceased).
L~ V1 h p. Htvt)saJ¿ty
10. Pursuant to W.S. § 2-1-201, upon presentation of this affidavit, any bank, savings
and loan institution, credit union, or any other like depository, held in the name
of the deceased, shall pay together with interest and dividends therein, to the
distributee or distributees as set forth in this affidavit.
DATED this lL. day of '"-) \.,\. ( )
ðDOO.
G_'~ff>'#c;~~
STATE OF WYOMING )
) SS.
COUNTY OF LINCOLN )
'J . The!;¿egOing, instrument was ,acknowledged bef7!)e by
!4h1ifL .' 4U!Ah", thlS-Ldayof /~
WITNESS my hand and official seal.
·200;- .
My commission expires: fft:J ~ 2tJJJ.f
ANJI TAVLOR NOTARY PUBLIC
COUNTY OF ~ STATE OF
LINCOLN ~ WYOMING
MY COMMISSION EXPIRES AUG 3, 2GGa
Page 2 of2
....~
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CERTIFICATE OF DEATH
State File Number: 2008007542
Martha Uta Hunsaker
000Q74
/
DECEDENT INFORMAT,ON
Date of Death: June 27, 2008
City of Death: Salt Lake City
Age: 84
Place of Birth: Afton, Wyoming
Armed Services: No
Spouse's Name:
Industry/Business:
Residence:
Mother's Name:
Facility or Address:
Time of Death:
County of15eath:
Date of Birth:
Sex:
Marital Status:
/ Usual Occupation:
Education:
Father's Name:
Facility Type:
18:20
Salt Lake
May 11, 1924
Female
Wido~ed
Homemaker
8th Grade or ~ess
FranklinBurton Steed
Hospital Inpatient
\ ' ,
\.
Own Home
Smoot, Wyoming
Pearl Debra Lehmburg
University of Utah Hospital
INFORMANTlNFORMATION. . ..,.,.i ....,. "...". '..".'., ...'. "'. (g¡i1~
Name: Pam Jones.trd"';'".:' t t Rel¡;¡tionship: :, ";rD~l!ghter
Mailing Address: 468 North ,3950 Ëast, RigÞY,ldabo83M2" . ..,. i:
;,;'~f ',)' --"~,'"., ,.',:..;- ," , ,;r.-·'· "-,, I,.,. .... ," .~;'::;::~~~;;'.':~.'
,'.:;~'" ~'·..,d:,-." '" *' (..
-- "'::'", . .\,.' '~.. ,"',;';;"
, Date,of,Disposition,;JUiy 2:~~OÖ~~,~
"':'::';;'...-;.1.-1'.,
DISPOSITION INFORMATION ,"i'f
Method of Disposition: BuriaIÎR~möVal,i', "",,,,.,,
Place of Disposition: S~99t ç,~ITIt;!t~'Xr$ÌT1oot, ,vyyoìTtin~
'~j-:¡jF~~:: .,', '. ~"::'" '<::: ;"~(,;,,.. ·-';:.i:~~?~~
~-i~".'·- ,.,.., '·"'-:"C,
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FUNERAL HOME INFORM. ATION,,, ,... , .. ,'... '. ,.,.t';".' :.J\l?;j;.,[:,/:'¡:""\':, ';
Funeral Home: \'f3offMoptua,rY,;", ,"""",; .;..... :'>;L '.. .', ',j."':
Address: "8090,South State, Mid..,.ale, .utah 840,47;,,.' .' ",¡:,r:,{.'>
Funeral Director:;j,¡pel B~lIaqj '"',,,..:::'" :', "éc..i\' ";:'i""';:">:?") ,.·t<;,::~\'~, ;'1',
M~~~;i~~:~:li~:;: TI;p.N ~j~'~¡~~~.Nirula;~D/5Ó·~·~rtr L~~i~;~~t~\0t:h 841~2
C~~~~~:c~~~~njUry Id~se"~5 J¡,yS] . ,:~,iJ!:'(;ì¡!Yt¥l'~,' ,<!i
Ground Level Fall [Onset;.5Daysl,;:,'C,':"'{:t
Tobacco Use: ''Nön-user'::;'\X:!,,;;: . '. ;;;, ' . . ,'.'..' ;i::' ·.S;'¿"{
Medical Examiner Contactêd';Y;ê~~~toPsy Pèrigrmåd:' ~q":;,ly1anr:)er.oF6~àth:'ðcèident;iïß,
:,.'.;"",:'" '_ :,:'J:'" .;'. ,.'.... '" ',. . ,.',,' '" "':.'-~_ ..;\..(:.... ,,:..'; '" -\;, .,-'...... ;". " ..",-: t
'__;:," ::.\::~:~.;:~; '".""j '~,':~. "_-'<~;'i ,:.":';, ':j~ <~>.;,:,:;:,~~;~~,
"t." -::::,:::', . ._.:,1,,-,; ;;< "~": --" ~" ,.'..'
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INJURY INFORMATION
Date of Injury:
Injury at Work:
Location of Injury:
How Injury Occurred:
Motor Vehicle Accident:
';:,,-.:!,
'i.'i!--~-;'
June22,:iÒÓ8
~ ' , ;:.'.'.\,'
No ';:',,~.{/{ '<'>~
77480 U',9Hwy 89, Srr1Öot;yyyoming
Fell and struck head on kitchenfloor".,
No .,,, ."',
-;",'"
" Time óf Injury: ," .." 16:Qg ;",,,,i,';
Place of Injury:,~ iU Deèe'de¡nt's!¡gêsidEmce
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July 1, 2008
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This Is an exact reproduction of the document registered In the State Office. of Vital Statistics.
Security features oOhls official document include: Intaglio Border, V & R Images In top cyclolds,
ultra violet fibers and hologram image of the Utah State Seal,over the words "State of Utah". This
document displays the date, seal and signature of the State Registrar and the CountylDlstrlct Health Officer.
(
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Barry E. Nangle, State ~eglstrar
Office oflVltal S,tatlstlcs
1IIIIIIIíWIII~~I' ,'~.:~
* 0 6 ~ 6 ~ 5 7 7 3 * Dlrector/Health Officer
CountylDlstrict Health Department
./
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