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..___.VING # 942164
BOOK: 704 PAGE: 634
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
WYOMING AFFIDAVIT OF COLLECTION OF ESTATE ASSETS
In accordance with Wyo. Stat. Ann. §§ 2-1-201 and 2-1-202
.
A copy of this affidavit must first be filed with the county clerk of a Wyoming court of competent Jurisdiction with a
certified copy attached to this affidavit.
This affidavit form is offered to be used In connection with .- 40lelyas a convenience.
Wells Fargo employees are not authorized to advise or assist individuals in completing this Affidavit.
Questions or concerns should be directed to an independent legal counsel.
To:
Certified Copy of Decedent's
Death Certificate to be attached
to this Affidavit/Declaration
STATE OF WYOMING
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COUNTYOF.~
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~nd~~;s~~~e:
1. I am the claiming successor of the decedent because I am the
decedent. .
2. Name of the decedent: ~7t¡~~
3. Date of death: b -.1 0 ;¡"
4. State of decedent's residenc~ at date of death: W Lj
5. Place of death: Ro..LlJ-eL.n..a ,IA/ Y (city and state)
6. The value of the entire estate, wherever located, less liens and encumbrances, does not exceed $150,000.
7. At least thirty (30) days have elapsed since the death of the decedent as shown in a certified or authenticated copy of the
decedent's death certificate attached to the affidavit.
8. There are no other distributees of the decedent having a right to succeed to the property under probate proceedings.
9. No application or petition for the appointment of a personal representative is pending or has been granted in any
jurisdiction.
10. I am entitled by law to payment or delivery of the property, and I request that the following described property be paid,
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11. e . in 11irs' a'ffida re'1fcre ~d~~~false statement may subject the persoll
or persons herein claiming to penalties relating to pe~ury under the laws of the State of Wyoming and any other
applicable law.
(Name of person signing this affidavit) the
-'~
/ .
(describe relationship to decedent)
of the
Signature of Affiant making the above statements
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City, state, zip
Subseri ed and swom to before me on the
day 0 \ r- ,20 D'b .
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QUINE CRNKOVICH - NOTARY PUBLIC
County ot State of
Lincoln Wyoming
My Commission Expires Aug. 1, 20-12
Notary Seal
State of Wyoming Affidavit of Collection where Estate does not exceed $150,000
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,DEPARTMENT OF HEAL1"H
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DEATH CERTIFICATE
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Decedent:
Name:
'qGender:q .'
bate cJf Elirth: '
Angelique Marie Deniz
,qFemaleq ',q'
lvIar¿g07, 1963
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Stite¥iI~NJm6er: 200S-001eb2
, Social$eclJrÎW Nµrrb~r:" -"
~ge atthe l\~m~ o~Deat~; 45 yef:!rs
Date and Place of Death:
f~:~r:~~;~~:.··. ','..~~~i~~ð~~~d~i:.~rô·~'gjê:("'. .....' ,',.,,'
, "AdditiórÎal;Ôeèede~t. ït.fbrmáti(;n :t\·q~"
,'.," qPlace Of Birth: San Bernardlno;,CaliforMia
Residence: / Rawlins,Wyoming'·..,,'..,,: ':,
~r%i~~~~~ð~~:~~?rce1"."i ':,{;} ".\
Name ofFáther:' .~ié:hard AWhitney'·. .,j'
Maiden Name o~, Motber:' Sandra M. Huggard
H!nforrTJáht"S¡;Indt¡;¡ M.VYhltl1~ý\ '
ÇÖ4nty ofpe¡ath: qárbolJ
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Disposition: . :"
M~thod 9fQispositioq:
Pläse ofDi~po~itior:r
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Funeral Home or Facility:i, , '" ..": ,I .' .'...,. .,.. '\
p'facility:PiP/'Pl ',.." Rostfld~ort~aty,'R~w!jns, VVYOh1irg\
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Cause of Death:·. '....'.,. ',. . .,:: .' , . . '
The immediatecaqse.Js /iste.donthe. ,fir.st1ine..fçJ/lowfJdby,anýuqderjying causes.
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,Nòt R¢cordeq
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(pMannêrof Óeath:~Natural Death
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Þ~ilil za~~få;:',~8toA~fY;. ,','
Box 6, Råwlins;Wycih1in~
YJpnep9, 2098
Certifier:H
Näh:1è:(
Address:
:time òf De.,9,-th:Q€3:00f\pprQ)<imate
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, PDate rpiled:<
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,} GI~dys K. Br~~den (
D~p~1y Stat~ Registrar '}
This Is a tru~ certification of the document on file in the office of Vital
Records Services, Cheyenne, Wyoming.
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