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Home My WebLink About944362 AFFIDAVIT OF I PROOF OF HEIRSHIP OF TO THE PUBLIC Ge...~trLJc, f· {jri1lK NAME OF DECEDENT OOO~'51 ,Q h' eh,o-<,j It tJrf'õ'Lk ,'11\ ~R 1,:CïrL €~or Parish of lawful age, being first duly sworn according to law, deposes and says that heirs at law of G ~rt n1..tJ-e E' \ 8 rl'iI'\..J<; that the said & <è:h.;t II" Il.,Id!«s in the County of J1j~ ~ P I~ J.ie c being (w:l !/,;L years of age at the of , a reside,nt of , State of F ¿lJrid A,... 1-/ e- is one of the surviving relatives and departed this life at or near , in the State of C~...lcr{"'d 0 '33(:a c c " tI ,~. c; C<£{ ¡ea..- , on .AJ¡j·~ I~ ;¿.D{'I'l death. The affiant further sw~ars that the following is a true, correct and complete statement of the family history of said decedent, and shows all persons who can be heirs at law. Was the decedent married or singlej a~r widower at time of death? If marriedja widow or widower, give name of husband or wife , address Is such husband or wife now living? Was decedent ever married to any other than above person? If so, give the following information: (List names in order of marriage) If dead, give date of death NAME OF SPOUSE OF DECEASED LIVING OR DEAD DAtE OF MARRIAGE DATE OF DEATH DATE OF DIVORCE -----..--- I If spouse has remarried, so state If deceased had children, name all of them, showing which are adopted, illegitimate, living or dead. If illegitimate, state whether living in father's family or publicly acknowledged by him. NAME OF CHILD OF DECEASED £ uat:: 'l1ë ,5 .' 8 ,.Î )~ AGE ADDRESS LIVING OR IF DEAD, GIVE DATE DEAD . ichcu--d 4, ß ri 1tK - (.;t.1I ~J L (nD ~,$~~¡¿"C-f) 43;j $l.0 ~ocl·t.h l¡;}N¿~ L ðccdc.... PL .3L¡I./-J'1 l B 1 r I I RECEIVED 12129/2008 at 10:38 AM RECEIVING # 944362 BOOK: 711 PAGE: 851 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY (Over) RECEIVED ~~"" 1" 1008 0/0 DEPT. LO·644 pg. 117·B91 Pfinled in U.S.A. OOû852 State beTow whether or not deceased children, including adopted or illegitimate, left descendants, including adopted or illegitimate. NAME OF DECEASED NAME OF CHILD OF DECEASED LIVING IF DEAD AGE ADDRESS OR SON OR DAUG'HTER SON OR DAUGHTER DEAD GIVE DATE ., .'~' " -, NAME OF DECEASED SON OR DAUGHTER I ~-,>. NAME OF DECEASED SON OR DAUGHTER DO NOT COMPLETE the remaining questions if the decedent left a surviving spouse and surviving children (or descendant of deceased children. Did the decedent leave parent or parents? NAME OF FATHER AND MOTHER AGE ADDRESS LIVING OR DEAD IF DEAD GIVE DATE FATHER MOTHER If deceased had brother or sister, give names, showing whether of full or half-blood, adopted or illegitimate. NAME OF BROTHERS AND SISTERS BROTHER OR AGE SISTER ADDRESS_ LIVING OR IF DEAD, GIVE DATE DEAD --------- State below if any deoeased brother(s) or sister(s) had children. Name each one, whether living or dead, and give the informatio called for in the blank form. NArv1E 0;: DECEASED BROTHER OR SISTER NAME OF CHILD OF DECI::At>ED BROTHER OR SISTER AGE ADDRESS LIVING OR DEAD IF DEAD GIVE DATE ·...~.:. t~:~ c.Oô853 Did dec·edent leave a will disposing of any part of his or her estate or homestead? Was there an admi:~1istration of estate of this decedent? yts In what8'Parish? ;1RIJfAJhe. Have all debts against the estate been paid? tc.S Did decedent leave personal property of sufficient value to pay all debts? y E..S If decedent was receiving payment for the accruals to any mineral interest in land claimed and occupied by (him) State? Ce.., (her) as a homestead, describe and identify said homestead land: Name or Affiant (Relationship) Subscribed and sworn to before me this day of ,19_. My commission expires Notary Public Address: State of County of This instrument was acknowledged before me on , 19 __, by My commission expires: Notary Public Printed name of notary: SUPPORTING AFFIDAVIT We, the undersigned, of lawful age, being first duly sworn according to law, depose and say that we fully understand the fact¡; and statements made in the attached ¡¡ud foregoing aííidavit of ; that we are personally acquainted with the affiant and are witnesses to his signature, and also were acquainted with said Deceased, and we know that the above and foregoing shows all the kin, relatives, or descendants of said deceased. R. J ~ h A R'¡ A ell)' ,¡V' /( Affiant: ~ ¿/J¿, £þ Address: Occupation: Affian t: Adqress: Occupation: Subscribed and sworn to before me this L±k. day of j\.)N ember ,~ól~i. . _PûIC00I,(CJ cYL/, d- Dìb1 Address: ~ .:<) èù ~\W \ Ob S\- _ "b OC\ \ q "Ç"' '-34 Lf6 \ My commission expires ---.1\-0 ~ Notary Public State of ~\ è/ \ J a County of }--1Gl \ D(\ . This instrument was acknowledged before me on _ ~ 'O."j 0 lV"be r L{ , l'Q ( ~-\DLQ'l, åç '1 C\L My commission expires: o L rib\;¿' Notary Public lO-644 pg, 4 1/-09 OOû854 HEIRS 9F DECEÂSED BROTHER(S) OR SISTER(S) (CONTINUED) NAME OF DECEASED BROTHER OR SISTER NAME OF CHILD OF DECEASED BROTHER OR SISTER AGE ADDRESS LIVING OR DEAD IF DEAD GIVE DATE NAME OF DECEASED BROTHER OR SISTER --.---- DO NOT COMPLETE if deceased left surviving parent(s), or surviving brother(s) or sister(s), or children of deceased brother(s) and sister(s), or any combination thereof. NAME OF GRANDFATHER AND GRANDMOTHER AGE ADDRESS LIVING OR DEAD IF DEAD GIVE DATE PATERNAL GRANDFATHER PATERNAL GRANDMOTHER MATERNAL GRANDFATHER MATERNAL GRANDMOTHER Name each uncle and aunt, whether living or dead, and indicate whether PATERNAL or MATERNAL. Give all informatioJ called for in the following blanks: NAME OF UNCLES AND AUNTS UNCLE OR AGE AUNT ADDRESS LIVING OR IF DEAD, GIVE DATE DEAD ----..-.- --.-'-"- --.------- State below if any deceased uncle(s) or aunt(s) had children. Name each one, whether living or dead, and give the informatio called for in the blank form. NAME OF DECEASED NAME OF CHILD OF DECEASED LIVING IF DEAD AGE ADDRESS OR UNCLE OR AUNT UNCLE OR AUNT DEAD GIVE DATE NAME OF DECEASED -+-- UNCLE OR AUNT NAME OF DECEASED UNCLE OR AUNT J" .- ',. ,~ _.._'.r.. ; nl'!;, -\ ,i'·;'::;·.';~'\' , ~~ .1 VJ Ü:n' ;~ p.h;\~ .~,~ h" ~f}. :'';~.~ ~·H ~!J'~ ~'·'\f;k.irt :. h. ',;-:- , ('¿~~:j , -"., ., .,. ." ..\ " ",..., '~ . .d. .( u~ ' 'J .1~('t ,:"'1," :,;"i~ji<:, J ...~~~ '~:~:.~? ~·::,,1~~.' .J! ,.''t ~ ' ,..;~ '('- ~ \-';1 I 1 (ävet) .;¡;~'~""""''''··''''i$·'''·''f ""¡'C"_">i~""'I1iI"""'~ LO 644 pg. J Prinltd In U.S. Exhibit A to Affidavit of Heirship covering lands in Lincoln County, Wyoming, for Gertrude E. Brink Township 22 North, RanQe 112 West Section 1: NW/4 NW/4, SE/4 NW/4 Section 12: SE/4 SE/4, NW/4 NW/4, SW/4 SE/4, SE/4 NE/4 OOô85S .. .'.- :.... ,.'-. ., . ,- . .. ' STÁ"tè ibF CÒèÓÎ=lADÓ CPL;ORAQO DE~ARTMENTOFPl4BLlCHEAL;TI1 ANQ ENVIRONMENT HOLQ,.O LI(:>HT,.o VIEW~AT~!:1rytARK( ·····..i ..... . ST~t~ oFëqLoii~DÒ CERTIFICATE OF DEATH J STATE FILE NUMBER' ~" ,.:' . ()Ov85€ 1. O~CEDeNr~rNAM~· (~:~SCif1iddfl>~.'$tj' ..::::...'.::.:........ <". ,........., .". 2. SEX (3. ~:~TE· '?~DEA~~ ',. tMonth.D,y. Ye.r) . Gertrude· .¢yel:& BJINlt .) .") ...... .'. :Few~!e LI\1~X,06,~Qº7 4. SOCIAL SECURITY ¡. 5a. ÅOË:·las,- ~... 5b UNDER 1 YEAR . -~~ :ÜNOER 1 DAY ·:·:·;···-;··ø.'DATlfoF.t1IRTH. ,.:. Ii 1. BIRfI'tPLACe·" (C/ly é/'Jd 51.,. or FO~lf1n NUMBER ! Blrlhday (Years): Mo. : Days 1 Hrs : Min. . -! (Mon'h" Day, Yeer' COUtltry} '~:,:;:.~i:'"r~~' ~"F;;¡[J~'~-='1-;,;f')~":'·~M==-i!""A!;.;:\:,-=--~,,; 9b:-.;ACV.I~¡~ ÑAM.:x. . .-Ê~.~'~Ôï~.'.';'..;;.;~~ g/v. ; ;ù.-;;r.;.~.d.~;~...;.::~1 .. o:~ ERI.·OUIPal.I.'nl ..........D..DOA 9c. ~~~V'-T~:~~~~D~o.'.CA. ~&~. F~~~~H 'XOthor i~'cifYJ HI!,~r.~è'2õüNtvõF-.ÓëAT'¡--"'--··"- Denver Hospice (Cnr.e Ce~ter) .... .... ... Aurora ~røpahoe ;0;., .oJ,cÊDEþ.-.-šüsu.iALõc.. c;UþAi1õNoI....7~ ..- -- .,... ·.11-1Õb~K¡¡¡¡'-ÚfiÜstN~S."!1N~~ST~,\ __. ---¡i'"MA~US:-M';;~õd;-T1iSPÖUSE -¡Ï/wIt., ;ï;;;;;~;"';;~.,;;~) - -- - -- ..J</~lun ,~WcJrl:I:è1on_.~unngmo.' '~rl{/nf/llffl. .:..:' ..- ." ....../...."'..-<.'...,'.-.".'"' , Never Mlllmed.WldowCld, J ·öo· D:Q1 tI,.·,./lred.)~. :'1 ,..,../.<:;í~::: .'::;~..:A:'.\ /. '='"'~ 'I, ,..~ Divorced t'."ecify} (;~i:~:~:~;::'1" '~~:.~~~~~~·"~1~~r71~~;~b~~, (¡t/~"MKldle,l8.$r) ./' J:i;:>~,~~~:.: ..-. .--.(. . il\;::¡'~';; ~.:;'. ..~.~~ ll~"fj~~" '" ·->f'i.(c&.~i~~~~;¡~~£:t~~~~ .... ~ 1\J (\I~' ' I,~,,: .... ..' ... ..........i ,.1>i/, ;MiMAY "9 "007 ." 23.TI t:o -r? .OATEPR~W'b~ .':,';.. ,:.::::,.,,;,:.~.::.__ ._,:\._~.-:;:,,.- ._......'~:\' /...,..~25.~~S;CORONER~TIFIEO.,' ,.,- _ jM~~u __" _ __~_': '" _JÓ¡:~,_:=:::~2;~~~~i~ :,c' t&3's.,l Jf~::~_- ---:_-~!"~-~:.- - - -- , ~. _~__~~_I~_----~'" TOBECOMPU¡nILIï!iPJl.9Ji1!.R.________'___ ; t8 end piece nd dUB ' . ' / 21...0n the b.,1i of examination and/or Inv8I1IAaUon. In my opinion dealh occurred at Ihe ~ ~ " time, d,11I end place, and due 10 the cau.els) and manner IS .I.IIKI. S/gn.'utf, '" .' "Slgn:'1Á ~ 28:tJATE S,(i'NÊ UDATESiãÑEQ "'-7MQñÎh,D;i.-y;;;,- -- ----~------..... ~~;Ji$..:d7.~ - ~~;;i.a)k-~"";."¡';"'Jcðj,/ ~ ¡ j ~ i I I ~ I I I I I I IE I ~~ I ~ ~ I , ~~ I ~, I I ~ i ~~ ~. ~. i ~ ~ i I ~ i !~ " / ~. ...;.-- I '., Peridlng Investigation . :.~...33a. DATE OF INjURY !. ':Jb. TIMe OF ..... :);]C INJURY A:r .. (Manlh. ö:..y; Y..rl :'..f' IN;./URV , WO~1K7 ._'_h".1 ____ __L ~"- -~-~- I 33....PLAGE OF .lNJIJß':'-Al-I:I9m~: farm~:~tr~~. f.ctoi:Y.~,.~ffiç~ ! /bulldIO"g, ~(c. (Sp~~/'Y) :;: ..>: \ '::::-... .::::.. ." 1:;3Jd,:diESë~.JBE HÖW:I~~-<EO·-: :jJ2. MANNER OF O~ TH :::: ..) ''I ·;133i.: i:~cÂ~ïoÑ isi;;;; ;~;, N;"';b'; ~;-Ã~;.íR~;Ñ~~b~:;;¡;~,cO:~,;: ;;d S"'·I ;:::1 :.: :.., .;.: Jtl:n¿~~~ATE CAUŠe I ENTER O~L Y ONE CAUSE PER LlNE-io~(i;, ii,J. AND lci;-- -·-·--löJ:~I-;ñll~·:~Ôd.'OI dy'n~::ié.Ã. c~¡.(íi.ic-';~·RISPlrøl?~\';r;.ti alon;;:.-, ... P~RT.. (,).,;<Jude .~ -£'4</UL- CONOITIONS .. OUE 1'~QR AS A CbNSEQUENCE OF) . >. .'. ......... - ./' .... i" . ...... Ë}i~~1~uSE Ibl oUE~~~~~~~~i~Þ{4~~. ." ~~i~~tNG CÞ:USE¡,),i. < ................ ........ ......> ..... P"~T ,:':OTH~.~ sloNi:FIC;AN! CONOITtq~S.-.c. Ondil1O:~.I.'.lJnl~!þUllf1fl.}.:Q !:h'llh but :~.:-rnr.· Illed 10 c8!:':~.' In II· ·PA~T ~·II.R.. IIICdhoJ øbuse, obe,itV;Slnol\ef)- ..:-'. ...,:: . Y:. . .<.. \.:. ::' Suicide '!J Undetermined . Mønqer .J i~,~;; ·be'~~·e~~~s~i .. ! and dealh 1· ;Lat/.$ Inlerval belwyf¡ onsel .:.' -I·IÌ~~ d88I~/ .::.. '.. ......,~.S' . :. ,! .In/~ belween onnl a;¡;:~ltI 35¡::AUTOPSV .. . '3i!CjF vES ;"'8r.:fInd¡nti:~·toIHlllderað ": (Ves or Nor In d~~ennln~ caul:' Qf.(føalh7 ..,-..,---.'..-...- .. ..._-~--_._.._.._. I ".,.__ _...____J ·';1: .' "':', "...:" ....-.-....-.. .'..',' .:'; >;. ',:. MÀ Y'09'2007 .ADRS.16H~ (Rov,1·91) ',~, DATEISSUED.··· UIlS IS AhUEC~TIFI¿ATIO~OFNA~ ANt FACT;XS REC<?RDED IN. THIS OFFICE, Do not accept unless prepared on ...s..ecu~typaperw...lth engr...a.,ved bord...e. r. diSP......layin... g th...e CO........1..òra...d.. 0 &,tate.....seal. and sIgnature?f the RegIstrar. PE~ALTY B'( L~W, Section 2'5-2.118, Colorado~evlsed Statutes, 1982, If ayerson alters, uses;·attempts'to·' use or furnIshes to another for deceptIve use any vital statistics record NOTYALID IEPHOTOC0I'IED, ' " ....~s:~ ... " .'. . ..;. :::-: ,... ....- .::;.:.: .::. ..' .'. ....- - ..' -'- _.:,,:. ? . .>RONALD S.HYlii1ANi .... / .. '~, STATE REGISTRAR (jllllllll~ IIIIIIIIIIIIIIIII~~ ~ 11111111/1 o 0 3 4 4 5 9 7