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Home My WebLink About944699 .;.. '-. .'" . Ji . j. '..: TO THE PUBLIC AFFIDAVIT OF PROOF OF HEIRSHIP OF 6e-rt r~/je... I', ßr/'ni( NAME OF DECEDENT 00&102 f? icht\.f·J 111 { R ¡ Ú"},\ ,4. /?r/7LK , a reside.nt of , State of ¡.:t..tJ/ì'J¿<.-> , County or Parish of lawful age, being first duly sworn according to law, deposes and says that heirs at law of Ge~'":'Trf....l.dc.. ê., ß rhtK that the said G c';IrTr£.~jc- £. ß ,...,.; )I..N{ departed this life at or near 33Cfq S:-~ ¡j,l.tfl e.. in the County of ARIJP/JJlD~: , in the State of C!¿?/Ôrâ..cJ.l\ ,on /fM Ý ~ ';¿ð¿) 7 being 3;2. :/;2.. years of age at the of death. He- is one of the surviving relatives and The affiant further swears 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 single/ aSor widower at time of death? husband or wife 5T¡'¡IV'J.~i 1\,1. -;g;./'HJ{ address , If married/ a widow or widower, give name of d c:,' c: ,1.S¿ J Is such husband or wife now living? 14/0 If dead, give date of death ~ I ¡, - /1 t~ 'I Was decedent ever married to any other than above person? 'l&:i If so, give the following information: (List names in order of marriage) NAME OF SPOUSE OF OECEASEO LIVING OR OEAO OATE OF MARRIAGE OATE OF OEATH OATE OF OIVORCE 5ÏÎJ,vLe..¡ /1../. 13fi.>1 A..-,j(' det.',~,;~~J t';t./-- j 1 ' /'i31:..· LJ 7 - ¡¿-¡'its, 9' Ole¡, ;/3 - /c¡¿¡, fi,tc~ e/j ¡t). /Ide/In Aiv' .d ec-,?':\Sé.d (! ,:}t 11)¿.:nL.. // - / j ".1 '1 79 L ,:¡ L<.) ., 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. LIVING NAME OF CHILD OF DECEASEO AGE ADORESS OR IF OEAO, GIVE DATE OEAO é '-/û¿'; -rltP.. ~ f3 ri ìt.K 7/ 3 (il) Co Rd ([i iIGt I í ¡,... B rCL:)'\.SðK ,11LJ ~SiPll, -9J :¿¡ if lê-)7AïJ A. Ii rl'í'lK 7~ S ~3;J. y" I 0 ¿,l3:h L'Ûl ¿ i1J L. . k /)¿"~.4L ¡IJ FL 344/1 \ RECEIVED 1/15/2009 at 12:07 PM RECEIVING # 944699 BOOK: 713 PAGE: 102 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY (Over) lO·644 pg. 117·891 Primed rn U,S.A. OOû1'03 State below whether or not deceased children, including adopted or illegitimate, left descendants, including adopted or illegitimate NAME OF DECEASEO NAME OF CHILO OF OECEASEO LIVING IF OEAD AGE ADDRESS OR SON OR OAUG'HTER SON OR OAUGHTER OEAO GIVE OATE '{."t,. '~'.,~~~ ,~.~;: ¡;:~ ~.> NAME OF DECEASED SON OR DAUGHTER . - NAME OF OECEASEO SON OR OAUGHTER -._-_. DO NOT COMPLETE the remaining questions if the decedent left a survlvmg spouse and surviving children (or descend a ts of deceased children. Did the decedent leave parent or parents? LIVING IF OEAD NAME OF FATHER ANO MOTHER AGE ADORESS OR OEAO GIVE OATE FATHER MOTHER I If deceased had brother or sister, give names, showing whether of full or half-blood, adopted or illegitimate. BROTHER LIVING IF OEAD, GIVE DATJ NAME OF BROTHERS ANO SISTERS OR AGE ADDRESS_ OR SISTER OEAO I ! I I State b,:lo'\v ~r c:n.)~ deceased brother(s) or sister(:;) had c!ï¡!drêiì. ~~aiì1ë:; ~â.ch ünc: whcthe.r li-ÿlüg or dead, aud give the infonnati II called for in the blank form. I I LIVING NAME OF OEC,::ASED I NAME OF CHILO OF LJECEASED AGE AOORESS OR IF DEAD 8ROTHER OR S!STER BROTHER OR SISTER DEAO GIVE OATE I I LD-644 Pi- 117j-891 Pnrnlld in U.S.A. "':"" ,,'¡;.~' . ,..,.... ,f'bOoio4 :IEIRS OF DECEASED BROTHER(S) OR SISTER(S) (CONTINUED) LIVING '. IF DEAO NAME OF OECEASEO NAME OF CHILO OF OECEASEO AGE AOORESS OR BROTHER OR SISTER BROTHER OR SISTER OEAO GIVE OATE - NAME OF OECEASED BROTHER OR SISTER '~'~:¡;""'"""Þ',...,...". , ,..1. .'"'',''-''' 1"11f'.': #i lU¡"¡')"")J-i .1'; 'i-ì' .';'-::v"< \ :-:~." . ! c ,.., 0;1" :!. ';."'f. \\. '~:",~ )0 ~OT COMPLETE i~ de~eased left surviving pa~~~~~l~~·~iq~~:~HFi<~v¡~:~§~rbÓ~l~i;~i~f.,::~i,ffi+,r(s), or children of deceased brother(s) end slster(s), or any combmatIOn thereof. .-1 O! t)ii¡ r.,a \, 'l.8·:'·,:i"',' : ",;.;..':;:;,;;.., ~¡ >t~ NAME OF GRANDFATHER ANO GRANDMOTHER -ii' Ji':'.', '.n1íif~~'r,,·~:~:-~:r~';>¡";"" \t.).' " ~ . AGE "-\,<.1' '.. ADDRESS LIVING OR OEAO IF OEAO GIVE OATE PATERNAL GRANOFATHER PATERNAL GRANDMOTHER MATERNAL GRANOFATHER ·4~:.· :r ....~, \e:.~,f.~:~':~:.~ ?:.:I,},.::_;.' ,.~t,;¡.t(·~~ MATERNAL GRANOMOTHER "","¡;~. ;:::"fi I ~ame each uncle and aunt, whether living or dead, and i~~i~ate'$&6th~~"t'P'ÂT~~~E()gr'(~ATERNAL. Give all information aIled for in the following blanks: NAME OF UNCLES ANO AUNTS UNCLE OR AGE AUNT ADORESS LIVING OR IF OEAO, GIVE DATE OEAO itate below if any deceased uncle(s) or aunt(s) f7ad children. Name each one, whether living or dead, and give the information aIled for in the blank form. NAME OF DECEASEO NAME OF CHILO OF OECEASED LIVING IF DEAD AGE AOORESS OR UNCLE OR AUNT UNCLE OR AUNT DEAD GIVE DATE NAME OF OECEASEO UNCLE qR AUNT ! I . "!.f)"';'':.'!.' . .. ,." . ". '-' ", '., '. . ~ r·'~~~~,.'I':· :'.'!,:L'1 ·1,..··;:1 " ~ (.;.ì C'!-:': ,'". '.. ...... ' '.' ....:.: .' . ,~ n ~.:" NAME OF OECEASED .,i', ,~, : . '/'. UNCLE OR AUNT , '~i.,. ,.' ~~ ':, n.," ~11! , ' ;'\{. ' ,tr\": (Over) [0·644 pg. 3 17·B91 Prlm,d," U.S.A. \ :) PQ·~~05 ,ø,. '.' "~ ~-. Did decedent leave a will disposing of any part of his or her estate or homestead? Was there an administration of estate of this decedent? ì) {'l-~ In what County-Parish? /.f J(ð¡ø~ h rrJ.Z State? t:. p t.. '/ Iii. Ji / Did decedent leave personal property of sufficient value to pay all debts? Have all debts against the estate been paid? '-oj II { I' If decedent was receiving payment for the accruals to any mineral interest in land claimed and occupied by (him) ", <; ¡.,llrtd IJ rJ t1 ¡ IV ¡, ~~n~ I I I L I I I (her) as a homestead, describe and identify said homestead land: Address: ""...."" .:13œ''''~Y ''(It?~ LILLIAN BATE ~t ?I I. . . ~ Notary Public· State of Florida .. ...\e,t:i \"1 ~¡ My Comm. Expires Oec 6 2012 State of ¡?¿ \ ...:t,?f.!,~~': CommIssion # DO 8,6',10 County of 1- This instrument was acknowledged before me on ~1.aí~ & Name of Affiant (Relationship) Notary Public My commission expires "L . LESUEH otary Pl.!blic - STATE OF Taney 072 My contml8lion e Notary Public i I I I We, the undersigned, of lawful age, being first duly sworn according to law, depose and say that we fully understand the facts and statements made in the attached and foregoing affidavit of 1'\ ; t- h A It ¡;¡/ A.. í3 t~ .1 N jt L ; that·we are personally acquainted with the affiant add I G-g1~ r fil YlrO € ~:i /3 ~J"'" U I are witnesses to his signature, and also were acquainted with said Deceased, and we know that the above and foregoing shows all the kin, relative~~ or d~scendlnts. of said ~eceas.ed. Affiant: \. ¿ \i l C Xli! I \. r (LCLCL( Address: J::¿'6t) I ~~" l-\i,\.Ll ~LÍ '6 '~~~~~~ì ffiC- occupatio~~J_J'~ Lt \ ~CJCÁ.A J~ t ~k( ~d Affiant: ¿~J¿,:( .ðA./~þ Address: '!3 f'tJ q 1/ h ~ .~ d--71.;L.¿"''L.. 77 £" ~ / Occupation: r;iJtfL'þ';"~ ".-.:~ 1--' I I l ¡¿d ~g té> I Subscdbed and swom to bcf me me th~ Jo±i:L- day of -J o.\¡ WI....y '. . ~Ie My commission expires iJdD..ber 3 I ;}¡ 0/1 Address: I ,{-YiQ'I ~ . He en ì e fJfJù.U /50 I Sf I+wl1-4 g Notarirubhc ßrv.n SOf\ I MO 05'" I (p LESLIE HOENIE Notary Public -Notary Seal , STATE OF MISSOURI State of Jd. (SSDU rt T~~:l9~f~~ty County of ""1ã:\1e~ My commission expires October 3,2011 This instrument was acknowledged before me on ,19_, by L I I i I I [ I i I I I I i I Notary Public My commission expires: ~ Printed name of notary: lD·644 pg. 4 17 891 Printed in U.S.A. STATEOFCQLORADO COI...OßAqO DEI?ARTMENTOFPliBLICHEAI...TI1 Af'41) ENVIRONMENT .. ....HOLQTO LIPH]TØ VIEW)'lJATERI\IIARK/ ......./ .... ... ... ... -' .-. STATE &¿bLciAADO\, ······OERTIJiICÅTE OFDEA TH , 'iTSTATE FILENUMBE~" / I ·3;.pAT~_,9F·{j"E~rH... {Man/h. Day, .'(ear) .. "'J . .. SOCIAL SECURITY ! 5':AG~:e{.~p~~t 5b uN~J:1t~AR I· ~(tWt~~OER 1 OA;;_ [)i+ËÒF~II\TJdd; "~~.a!e i~¡,M'+'2~:.J2~jtr,¡,., sr.i. or ¡ii-.",n NUMBER .... . . ." '. ¡ Blrthd.y (Ym,) I Mo, .. . O,y, I H..: MI", . ; (Monrh. D.y. Ym' I Coun'", ·3Êe~Ê?l.J~~j;f:E~£=~~œ:l:~=::R::';~~=-~:~:~ 9b. FACiliTY NAME (ffnaflnsrilullon. p/ve ,/reet andnumb.r)· Be CITY, TOWN. OR LOCATION OF DEATH ]Dd COUNTY OF DEATH pe.IIY.e.rJ!!I~l'!.c."-lÇ~le C~!~___''''. Aurora Arapahoe 1.~a. ?J1feEr~~~.9í~:~9~~wPrl{'n~ Ii(,. l;õo-KíÑÕ ~ 8USIN~Ssll!,~lJ~mY k~-~1 ~~~A~:~~Y~~~~~d:--lr~PbUSS flf'tlifll. ;iv;-m-;ld.~-~8';;.J . . Do a2t -tn9.,w/lred.} :.',' I. ,-' r .',' ~ \," ; ,<" ø.vnroll~ (Specify) Home Mllller ! ciw¿ Höíne' 'Æ, '; ,,"" 'Di:vorced 13a.'ji~SlëË_ÑCE·.s~iÄ-iÊ "::r"3-6e:ë"ÕÚÑTŸ-' _n 1.- T f3ë~cTTY,lijw¡:toRloCAjlôN~M' '-~-, --:-~~_..- f3~AÑÕ ÑUMŠER----1- - .-- - ---" ; 13ì. iIP~~::p~~~e ,'14.··.t.:W:.:ík~..k.;.·~.,~.i. r:~~=I~::~.,c.'.':ó.l. Rì.cifN. i'.··..\:".....:, ::. . ::.....·.1,.·.. ,;: ;~).,.A.~2f.2.,~~..~..k'r~_e. el!~rg,·.~~EyC~~~~: ~-01 UCATION (s-- _..IU-;hoJ...Sf 130. ~~\?E . ~ ..," (SPaolly NÓ"r YO,.- II. .y", ,Pe<:lIy.C.ub.n::.>"'....· BI"k. WhU.. ~¡è. (Sp.¢iý¡ I ....d.,ømp..'.~ EI.m.nl.ry o,";.-';¿';;;':" ..... LIMITS? I ~' MexlcaQ,PulltloRk:an,etc.) ~:",;,' <:: ,,"'" .' ,,'~ ,',' './1 (0 fhrouph I'JCollege {13'hrough 160r 17+) 'X Yo' '¡S0014 10 No" ,'.Jy.. '.. ". -''', : ¡ White', ,', 1 1Z 1l¡_,F~TH:N~M'~;:'- ·.t;r~;:· Mlddf.J~;Ü -: -, ~p.~Jf:} ,"- ¡ 1; M~'t~R;ÑÄ~~~{f~I';;': ~lddl;. ~;;~;;:~eh~¡;è»\-~' ,;ïN;õ~MÃÑT ~ÑAMË;;;'-;¡~tlo;,Þ~;i.ç~;s~. - HllrrxEarl R.o.lll~~ .:,' "" ..., Flol'ence nW~Œ.:_~ ...._'-":.'___ :... ___' R clìar.!fBrlnll - S.'!!!_.__.__._ -.. . .-20..~~ETHOO.: OF ~~SPOSI!.~ON:,. 20b. Pl,ACE OF DISPOSI11ÓN , (N,me ofbem,,',ry, çremøfOl)', or' Oc. LocATION· elly or Town, Slall .' olfjerpf.(JcfI} C/ ~ ~; . "¡ r. B~ri..1 ,)( C,.~fn81Ion :::.. . ;::-R.tmOVål from Slste " , r 00".1100 ' Oihor (Spi.ly) .' ?~yì~~~adoW¡¡~'ê~fP~êÆii¡,6.§lI:.,·~~:~t.j,i¿o,n~~rte.ç,'t}',ç~I.9ia~o· .' 211. SIGNATURE OF FU~'RECTOR OR "~RSQN .' a.!.u,G~ . ..:; '" '-i'. !.,.,...b~,..~,~!"..E. ..I\.,..~D.A. Od.R....,E..~;.:.O. ...~..:.,,...~!.:~...~'.::...~.:.~~~?'...... /'~.... f'.i ) . .,,' ·Newcomer.Fph\lIyFunera\il'tome. Y {¡v1; ." .. " : If 0 f9fð~~FS!r;t~; ÁJ1~o~a, CQ.80011 '~rbURE t\)(\I~l ~". ~~. ,~,~~b'~AT~FIL~~MÃ;¡Õ')9 fJ007 H / ,:~:TEPR~~ð~ y I, :', Y..;...... ',.~~ ¡;. ~:;;;:?NimNOTIFJED,," 08:35.ám l ' .. 113' 1'1 ~.-' ,_ Ma.'/.._- _ ,_._ ..' .,,_ ,dl6_'"__._~_ ~,"::"2007 ' ....:,:~_. ..jL..§....L__,,_.._.____... . - - ~~ . - .., .. _.__." .._..______.:w C I etœ (~_".~~.__ ' " __~..,~:_..~,__...:...I.Q.H..Ç.~'t..~.R.ØJWt ------- - .--- 26. To the besl. of my k..nowlldg,r1fÍ1Ih occurred allh. . Ie and ple:oe nd due i:$- ¿ , ,. y: 2'1... On Ihl bllsl.. of .".mlnaUon andfor Inv..1IQlllon.)ln my opmlon d..1h ocouned II the ih. clu~e{alaod ml nir ~, , '.: ' ;/ <~ ~ ,\ ~,Umt, dale and JMce, end due to Ihe cevs.ta) and manner., slaled. Si(1netu(, _....~ .~~_. ~~"_.._......_~__-____-- -.--..--'----~- - -----, :119, PATE SIGNED (Mdnth, Day, Yøør) \ ~~~~,::2å C::i;';i~~rJ)];~ kOECEbENrS NA~E ;tFlii!;:Mfdri~;:t~S¡J ~..SEJ( ...., .-.'.... ....... ::. ". ,-:: ":'. ":. '::-: .. A1ø~~i.ç) ZI~Jw?1' / ::;.32. MANN~R OF ~.~ATH\.. ' :::.~ 33a. DATE ÖF 1o.JURV::: 1 ~!lb. TIf~tE OF . ::;:'" ·l·~~ç· INJlfflY.ÁT 1 33d~;OESC:RIBE ~~W}NJUR'ý::pctURREÐ'> " ~~~~\~:'lIon . ....¡.... :M..nth~~b'Y' .~·":·'·.··.l·...... ~~.:~~~.~..'.~~t,;_.:.=~~~.:..I.. ..~~.:._~;._ ..~...._..._.. ..':.. _._._~,_. ... .'..........",....,'..._ ..1. .." Undot.rminod i 33.. .PLACE OF.INJURY.AI.twm~, f.rm...."r~..,. raDIo<):. of1i~. J;¡;¡,. LOCIIJION 1&I,...I.nd Numbor or R~(1I1 Rou," Numbor. Clly. Cou"'Y. .nd S,.I.I :::d.M·r'...:_\.b~II:';.~:....o:rsi'tyJ ",.' ....l.. ____\.d .JJJ.......dL'x. ._._j.__~----L-.}_L;:.... . 34. IMMEDIATE CAUSe { ENTER ONL Y ONE CAUSE PER LINE FOR .(~), (b), AND (c), 100 nol enlar ñiÞdé of dvlnjf(e.A_ C"fdlac or Resplratory"Arrest) a\on.;· '" ..- ¡Inlerval b.lween·on.et PART " . ~.It . Î ' ."d d..lh IIOI.Au.dt-.~ -:h:4.. ~/U-..... .... . ..1d!at./$.· CONDITIONS' OUE10 9R AS A CONSEQUENCE 0'\( . ........ ......... . )' ..In'orv.1 b.,"~oo"l Ë~~~1~~SElb} OUET~~~!sfa'tef~;~,iIÞE )i~n: ~J:£~~:,'/ UNDER, YING CAUSE .¡;:~'h ';:~~ (C)OTHÊR SIGNI;¡~A~T CONOIT1ÓNs.condlU.~' ,u~li~uu..;tOd~~lh b~'¡;"I;'I',"d '0 Jo" ~. 3~AUTOPSYi . ;tiJF YEi ;;~¡ëllndi~~~ OÓ1,KI...d II PAA.t 1-:(e.R., alèOholebuse. obesity. :à{P.o.kerJ. . . ," ". .' . {Ye'! or Nó):. In tt~.I..rmin~¡::¡ cau~. 01 (ealh7 .-.... -.--.-.....-...-..----...-...-.--....-..-. . ._----_.._~..-..-. i No n.J....... '(. . i ....1. ;{'. ""\:. \.:~. '):'" '. '\.::. \MÀY 0 92001 ············~NAL~·.~~··.·· STATE REGISTRAR ., ADRS·161.69 (R.V~ 1-91.t. DATE ISSUED ". T~IS IS A~uké~TIFI¿ATIO~OFNA~; ANb FAètSÂS REC<?RDED IN.THIS OFFICE. Do not accept unless prepared on secUl;ty paI!er wltl1 enl:;r~ved bo~derdisplayjng tile CQlor¡¡do state sea¡ and slgnature?r the Re~lstrar. PE~ALTY BY Lf\¡W, $ection 25-2f1l8~ Colorado RevIsed Statutes, 1982,1f a person alters, uses,àtte¡\¡¡ptsto'- use or furnIshes to another for deceptive use any vital statistics record NQTYALID IF:PH:PTOCOPIEP, . ':. '//.' . 1JIIIIIIII~III~ II ~II]II ~ 1111~II~illlllljl]111 ~l, o 0 3 4 4 5 1 96 . " .. " "I " HI II, 1111 ,'" ,,' I'. 'II,;':' 'I< I : !II " l,;hv NA txprn f"roeJ \';0 SCHEDULE "A" 0001.07 02503MAL Venture/DOI: 8084/1 State: WY Venture Name: SHUTE CREEK FRONTIER "B" County/Parish: LINCOLN Effective Date: 01/01/2009 Product: Gas/NGL'S Lagal Description: PRIMARY DESCRIPTION¡ 22N-112W, 6TH PM, SEC 1: LOTS 5(40.00), 6(40.02), 7(40.02), 8(40.04), S/2 N/2, S/2¡ SEC 2: SE/4 NE/4, E/2 SE/4¡ SEC 11: E/2 NE/1, NE/4 SE/4¡ SEC 12: N/2, N/2 S/2, S/2 SW/4, SW/4 SE/ owner Nol Taxpayer ïD owner Interest sequence Owner Name r Address J.nt:erest vecimal lnterest l'ay Status Type ----.-------------------------------------------------------------------------------------- B040111 ON FILE 1 GERTRUDE BRINK OR 0.OOOB6010 SUSPEND ...-------- StlBTOTAL OR :INTER.EST 0,00086010 DIVISION ORDER TOTAL 0,00086010 !1.,o:w¡a 1 ·...f