HomeMy WebLinkAbout947108QUITCLAIM DEED
OOCYS1 7
KNOW ALL MEN BY THESE PRESENTS, that ROBERT KIRK JOHNSON, Successor Trustee
of the CLAIR L. JOHNSON REVOCABLE LIVING TRUST, u/a/d June 28, 1976, as amended, of 4215
Hullett, Okemos, Michigan 48864, the Grantor, for and in consideration of the sum of ten dollars ($10.00)
and other valuable consideration, in hand paid, the receipt whereof is hereby acknowledged, CONVEYS
AND QUITCLAIMS all interest in and to the mineral estate in the following described real property in equal
shares to ROBERT KIRK JOHNSON of 4215 Hullett, Okemos, MI 48864, NANCY LEONE CHLEBUS
of 600 Laurel Street, Sturgis, MI 49091, and ELIZABETH KAY SAFIRSTEIN of P.O. Box 225,
Churubusco, IN 46723, as co-tenants, said mineral estate being in the following described real property,
situate in Lincoln and Sweetwater Counties, State of Wyoming, to-wit:
Five percent (5%) overriding royalty interest in the following mineral interest in Lincoln and
Sweetwater Counties as evidenced in Book 269PR at Page 342 as recorded on January 16,
1989 in the Office of the Lincoln County Clerk, Kemmerer, Wyoming:
T24N, Rl l 1W, 6`h P.M.
Section 17: N%z
Section 18: Lots 5, 6, 7, 8, E%, E%W'/z
CT T24N, RI 12W, 6"' P.M.
Section 1: W'/2SW'/4
Section 12: NW'/4NW'/4
In witness whereof, I have hereunto set my hands this t;/M day of P-c i t"? 12009.
ROBERT KIRK HNSO ' , stee
Clair L. Johnson Revocable iving Trust
u/a/d June 28, 1976, as amended
STATE OF tG C~A )
ss.
COUNTY OF ~'~t Ca o- )
The foregoing instrument was acknowledged before me by Robert Kirk Johnson, Trustee ofthe Clair
L. Johnson Revocable Living Trust on this -k day of ~40t , 2009.
Witness my hand and official seal.
t wy PtjiQc~ k,1*Men CrP' NOTARY PUBLIC
A My Commission Expires: 3 ( I c~U
wo, 6os4w,iu,*,n Es0w,- t 31, tx?11
RECEIVED 5112/2009 at 3:01 PM
RECEIVING # 947108
BOOK: 722 PAGE: 817
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
[NC3IAINIA 5 i A E IDE,""AR-ETi ENE f 0 - 404 p8: I
~a CERTIFICATE OF DEATH
Local No.
r. h..,., r"1 c.~ 1~,y V
1. Oecedunl's Legal Name (First, Middle, Last) r .v . State No.
Ia. 'Aside., Last Name 'll Female •
ELIZABETH R. JOHNSON ~r.:..4. 1....4..'_)..
l ) 21 Si 3. Time Of Death 4. Data Of Death (MonihionyrYaar)
T M
USCHELL F 1:15 AM APRIL 6, 2008
. Social Security Number 6a Aae Yrs 6h. Untls 1 Yaar 9 Under 1 H' Lb 6tl. Undsr 1 Dsv 6e. Untlsr t Hour
7. Date O( E. (hlonth/Day/Year) 8. Birthplace (City And Stale Or Foreign Country)
Q6
hours F4inatee April 17, 1911 CHEBOYGAN, MICHIGAN
9. Ever In V.B. Armed Forces? 10. If Death Ocrrirred In A Hospital:
.I Oa. If Death Oxurred Some"llere Other Then A Hospiiel:
❑ Yes ® NO Unknown ❑ Hospice Facility ❑ Decedents Home D Nursing HontelLong-
❑ ❑ Inpatient ❑ Emergency Department Outpatient ❑ Dead On.4rfival
Term Care Facility ❑ Other (Specify),
11. Facility Name (If Not Institution, Give Street And Number)
SHEPHERD OF THE HILL
12. City Or Town, Slate, And Zip Code
13. County Of Death 14. Medial Status Al Time Of Death
KENDALLVILLE, INDIANA 46755 NOBLE
❑ Married ❑ Married, But Separated ❑ Divorced
15. Surviving Spouse's Name 19 Widowed ❑ Never Married ❑ Unknown
15a. (If Wife)Give Malden Lasl Name 16. Decedent's Usual Occupation 17. Kindo Iness/lnduslry
N/A NIA HOMEMAKER HOM
18. Residence - Slate 16a. County
18b. City Or Tonn
INDIANA NOBLE KENDALLVILLE
10c. Street And Number
led, Apt. No. 18e. -Lip Code ns a Ily Imr
351 N. ALLEN CHAPEL ROAD
46755 ®Yes 11 No
19. Decedent's Education 20. Decadent Of Hispanic origin
21. Decedent's Race
Some college credit, but no degree No, not Spanish/Hispanic/Latino White
22. Father's Name (First, Middle, Las[) 23. Mother's Name First, Middle, Lasl
( ) a. o Br'S a an as time
CHARLES M.'MUSCHELL AMELIA MUSCHELL GROSSMAN
n orman s ame a. a 8' ns lip ac, en
al n1g v ress ree n um r, I y, a I. Ip o e
NANCY CHLEBUS DAUGHTER 600 LAUREL STREET, STURGIS, MICHIGAN 49091
25. Place Of Disposition
25a. Method Of Disposition. ❑ Burial 0 Cremation 25b. Place Of Disposition (Name of Cemetery, Crematory, Olher Place) FFORT ocal on - City, Town, And Stale
❑ Donation ❑ Entombment ❑ Removal From State NORTHERN INDIANA CREMATORY WAYNE, INDIANA
❑ Other (Specify):
26. Was Coroner Contacted? 27. Name And Complete Address of Funeral Facility
279. Funeral Home License Number:
❑ Yes 0 No D.O. MCC OMB & SONS FUNERAL HOME, 1320 E. DUPONT ROAD, FORT WAYNE, INDIANA 46, FH19500009
27b. Signature Of Intliana Funeral Service Licensee:
270.. Icense Number (Of Licensee
FDO9200006 MARK A. SHRADER
Cause Of Death (See Instructions And Examples)
28. Part I. Enter The Chain Of -vents-Diseases, Injuries, Or Complications-Thal Directly Caused The Death, Do Not Enter Terminal Events
Such As Cardiac Arrest, Respiratory Arrest, Or Ventricular Fibrillation Without Showing The Etiolo . Do Not Approximate
A Line. Add Additional Lines If Necessary, 9y litexiat Enter Only One Cause On Interval: Onset
To Death
Immediate Cause (Final Disease Or Condition Resulting In Death A.
Due Tol r /ton=yque OIr {
m) w
Sequentially. List Conditions, If Any, Leading To The Cause Listed On B.
Line A. Enter The Underlying Cause (Disease Or Injury That Initiated s Te cenee . o y r l/
The Events Resulting In Death) Last C
r,e r• (Or Af A Confnquence oil:
Part If. Enter Utlier Sir ~anl Conditions Conlributina To Death Bul Nol Resulling in The Underlying Cause Given In PaA t ~9TiV'eITFu opsy at pima
❑Yes No
_
era u upsy m ury vat a g o mp I9 a ea I
❑ Yes ®No
31. Did Tobacco Use Contribute To Dealh7 32 If Female:
]33. Manner Of Death:
❑ Yes ❑ Probao ❑ univiaym 10 Not Pregnant within Past Year O Pregnant Al Time Of Death ❑ Not Regill BU Pregnant Within 42 Days OI Death t
❑ Nol Pregnall Br4 Pregnant 43 Deys To 1 Yea Belpre Oeelh ❑ U1lknwm II Pregnant VYlelin The Pest Vear elural ❑ Hamieide ❑ Accident ❑ Pending kwestgaeon
34. Dale OI Injury (Month/DayKear) 35. Time Of In u uicide ❑ Could Nol Be Oeleimined
ry 36. Place Of Injury (E. G., Decedent's Home, Construction Site, Restaurant, Wooded Area) 37. Injury At Work?
❑ Yes ❑ No
39 Describe How Injury occurred T40. If Transportation Injury, Specify:
41. Signature, Of Person Cenifytng Causeseal l 13 oil erela ❑ Passel ❑ Pedasldan O Other S cl
low 42. COMES, (Check Only One)
®Certifying Physician ❑ Coroner ❑ Heallh Officer
43. Name, Address And Zip Code Of Person C;Pifyinf Cause S1f,Dealh: 44. License Number 45. Dale Cenlned
49. Additional Funeral service Provider:
47. 'Akas:
48. Signature of Local Heallh 0f8cer. 49. For egistrar Only - Dale Hied (Month/Day/Yeil
ADD Ell 200
State Form 10110 (R7/9-07) ATTENTION ESTATE: TM Sxbl eeewny a Is being requesled by Ibis sink sill In eider to pwsue Is sialurmy responsibiiey. Olscloeurs is W.Mary ant there AN be no Pi naay I. wens. THE RECORDS IN THIS SERIES ARE CONFIDENTIAL PER IC 16-3 7-1.10
IVRA-20
/7/nrl
0®iy819
ACCEPTANCE OF TRUSTEESHIP
BY
TRUSTEE
ROBERT KIRK JOHNSON, being first duly sworn upon his oath, certifies as follows:
The following Trust is the subject of this Acceptance: The Clair L. Johnson Trust
Agreement dated June 28, 1976, as amended by the First Amendment thereto dated
February 13, 1979.
2. Subject to my appointment as Successor Trustee by Elizabeth R. Johnson on March 14,
1998, I hereby confirm and accept my appointment as Successor Trustee.
3. Elizabeth R. Johnson died on 4/6/2008 and the sole surviving Successor Trustee is:
Robert Kirk Johnson
4215 Hulett Road
Okemos, MI 48864
4. The taxpayer identification number of the Trust is: 38-6690671.
Dated: ^ S - Ci /~'~.-i,.-------
ROBERT KIRK JO N, Trustee
STATE OF I k C U..! GCW
COUNTY OF
ACKNOWLEDGMENT
Before me, a Notary Public in and for said County and State, personally ROBERT
KIRK JOHNSON, who acknowledged the execution of the foregoing Acceptance, and who,
having been duly sworn, stated that any representations therein contained are true. Witness my
hand and Notary Seal thisS'~day of QL 2008.
M commission expires: OC~ ` 1 I
Y ~V
Resident of: 'j• c i C~1 c
Notary Public
I affirm, under the penalties for perjury, that 1 have taken reasonable care to redact each Social Security number in
this document, unless required by law. Jane M. Gerardot
Prepared by JANE M. GERARDOT, Attorney at Law # 15172-02
7321 West Jefferson Blvd. Fort Wayne, IN 46804