HomeMy WebLinkAbout948995r0
AFFIDAVIT OF DISTRIBUTEE FOR
TRANSFER OF WYOMING CERTIFICATE OF TITLE
I, Lynn Noah Ashment, being first duly sworn and upon his oath, state the
following:
1. That the decedent, Tyrel Richard Ashment, died on the 22nd day of
November, 2oo8, as evidenced by this certified copy of the death certificate attached as
Exhibit A.
2. That the decedent, Tyrel Richard Ashment was not married at the time of
his death and does have surviving children.
3. That the name of the distributees entitled to payment or delivery of
decedent's property is Lynn Noah Ashment and Lisa Alice Taylor Ashment, who are the
natural parents of the decedent.
4. That the value of the entire estate of the decedent, wherever located, less
liens and encumbrances, does not exceed one hundred fifty-thousand ($150,000.00)
dollars.
5. That more than thirty (3o) days have elapsed since the date of the
decedent's death.
6. That no application for appointment of a personal representative is
pending or has been granted in any jurisdiction.
7. That the above-named distributees are entitled to payment or delivery
of the decedent's property listed below and there are not other distributees of the
decedent having a right to succeed to the property under probate proceedings.
8. That the undersigned request that the following described property be
transferred to Lynn Noah Ashment and Lisa Alice Taylor Ashment, who are the natural
parents of the decedent, and that title to said motor vehicle be transferred into said
name.
9. Property description:
Year Make/Style Color Vehicle Identification Number
1996 GMC 2GTEK19R3T1543536
Bowers Law Firm
Transfer of WY Certificate of Title RECEIVED 8/19/2009 at 9:35 AM
Lynn Noah Ashment RECEIVING # 948995
Page I of 2
BOOK: 730 PAGE: 168
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
00016,911
DATED this g day of 19va , 2009.
d
Lynn oah Ashment, Distributee
State of
)SS.
County of
Before me on the /3" -day of &Pydt , 2009, personally appeared
LYNN NOAH ASHMENT, being first duly s orn by me upon their oath says that the
facts alleged in the foregoing instrument are true.
WITNESS my hand and official seal.
&,;&2 zE J
Notary Public
My commission expires: go 2-' ERIKA BENCH ~ OTARY PUBLIC
jy~.. M~
County of y State of
Lincoln Wyoming
My Commission Expires July 31, 2012
Bowers Law Firm
Transfer of WY Certificate of Title
Lynn Noah Ashment
Page 2 of 2
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1. DECEDENTS LEOALNAAE fftdmpA . AaMT IFM, Middy. LaG
s
x.6191:: :
I DATE OF DEATH QAND"Nn(Spot MOMrl
;
Tyrel Richard Ashment
Malb
November'22, 2008
A. 96CLAL SECURITY W&MA
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ne+W
27
rwwM . , <o.T.
HouN tAnuw
March 19, 1984
G
W
.
IF DEATH OCCURK5IN A NO~ITAL IF DEATH OCCURRED 'SOMEV*e* MHERTMAN AHOSPITAL
Q
L
7b. FACILITY NAME (W m18a1bdm, III,. Meat rW aerosr) Td;CITY;.TO4HL ORIpCATION OF MATT;. Id- rOUNTY OF DEATH
u
1336 Highway 239:. Freedom Lincoln
.
p
a. BIRTHPLACE (C[Y and wte;u (asipn cma") AIAfSTALBTAS AT Yrre; oP l7FATN", 1o SURVMN0 6POUSe
Merlkd .Q Menle4'bN ®Me1ad d Khdowad
EDI
I;
Or' m
Sheridan, omin M..w E2 thug
ND
AM
Y
t1.ENER IN U.S. 72a.REWDENCE-STATE. 12b COlRlfY.
12d. CITY. Tom OR LOCA .
6
c
ARMED FORCES?
LIMo~^.
s Wyoming!
- _
Freer Jom
I
!
.
1'M STREET AND "AMBER "
12e P COVE
12t, INSIDE CITY LIMITS?
72
Q
1336 State HI hway 239
83120
0 YES No
E O
13.FATNER'SNAE(Arat. Mdde,Lean
1e.MOIWNS NNE PRIORTOFBISTMARRIME(Rig. Mdda. Laaq
19
Lynn Noah Ashmebt
Use -Alice.Taylor
m
ik ItFDM1AM'6 NAAAE 15b REIATONSHIPTODECErIENT
t& MNUNG ADDRESSIaWNt and Nm".CJII': 6Te1e, 21P Code). .
Lynn Ashment Father
Box 917; Thayne, Morning 83127
16. METHOD OF dBPOSITION
1'Ip PLACE OF dePO&TON {Nnw.al
17A LOCATION-GTY OR TCMM AND STATE
BMa? 13 'oaia6on OiYemmrAaiilWTi.dro
amdan «PMOa)._
16e. SIGNATURE OF EUCENbEE--.
1Bb LICENSE ND:
1aa: NAME OF PAGLT[Y
Box1n Oi FAGUTY
1
ux 11221 1 44 E 4th Ave
Afton
(ape
A
426
Schwab Mortua
,
omin
2o. AG PRESLMEDTME OF DEATH
21.DATEPRONOUNCEDDEAD (MO'T]N'~Y1) 22.71MEFRONOUNCEO DEAD
xa. "M 001"" CONTACTED?
02:00 Approxlmaw::
November 22 2008 ' 12 00
~t YES CI No
:r;... CAUSE OF DEATH
F-die Main deverb-deawea hjM WM%AWms- VW dik"enued me Meta. 00 NOT iM-10*"ia"Wd1 mrdea - 'I AMOX11e1e iMe 91:
PMT I
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in
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..~...,++.n .s.apHV~e,YW.eeroNdmwd Mb1wr. ooNtlTAeMLYN7E: an. wry m, w..m.d+ Aa.eeeaw r.,. 0.0 W aa
1MMEGATECAUSE (Pi.W daewa : Toxicolooy Pendtn4
e
-'wndnorrNadniwmd.db)..: ~ IkIEI'O(bi:w
;
I
bgmeda y eamnda.w A e W. I
leadlprome oeuee egadmlm b:
6Aer Me llNDERLI'PIG fAI~e[ - DLIE TD (dfiaLPlbaWellCe OV
(daepq alNal'IhMiNleladlM r: I':.:
events-ftoin deadl) LAST 1 .
(
DUE TO (oi eA a caoe9usroa oq
: 'I
a.
PA" u. Emar emsr da k.M mnddem _dMM k".#, alb ba W rerdind In me uMxMlN cawy V_ P.,
25. WAS AN AUTOPSY
PERFORMED?
YES ONO
?B. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEA
TH?BUTE TO DEATH?
'O
O YEB NO
O YES O NO O PROBABLY UNKNOWN
Gr
2d. IF FEMAIEAGED fP51:.
O wee aelFNdL W pednmle3 dgsM Tysa 1,11- dedh
.
?O. MANNER OF DEATH'
❑ rbrddde
❑ NgAN
0
O E
a nPM Yaa
0 Na"W
O Acdd 01 Perldry PnedllPSm
U ul
U
C Prepnae wtam IXdeem Cl UnlwwnSgWn='A rllNn fia PxG yuA:.
O sdoae O codlunIXMa.iandma
m
:
O Nd prednwA. bulpWmm MUM e2 drye dtlMM1,
m
F
30. DATE OF INJRY PAdTaY/Vr)
.
31. TIME OF INJNTY
Pi G OF INJATY lDeeeded ham. rnimrudim dN, lerael, eta)
33.INAIRY AT WORK?
I NES O NO
3e. LOCATION OF INAMY (8bael end nwi- GN or Tavd. SMa)
35. IF TRItN6PORTATON ACCIOEM. SPEGFY:
-
❑ Ddver l Opwa 0 PedevMan
0 Pecea r . Cl Diner 6
X. DESCRIBE HOW INJURY OCCURRED: AND IF TRANSPORTATION INAMY. T(AE TYFE(8) OF VE"A01E(S) INVOLVEO.(Aatonioub, plcbup, mWagdi. ATV. Ngde. ale)
37a. CERTFIER (CM k aNY sin)
❑ PHYSIGAN-TolM bedIXm/loraMedps. daaR OTwrrp at meeme, dale and daa, enddmbtlro ouae(sl and nranrBr Anted,
i10 CORONER- 00 $ & e..de.rm, W f& i my dPMeA: de o aline bin, date -1.0- e W d..W IM.Pmlel end manna AAed.
_11b DA-
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C. MADOMS. tv
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Maryanne Christensen Deer Coroner
WY 831
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This is a true certification of the document on file in the office of Vital f~2J
- el
Records Services, Cheyenne, Wyoming Jl
JAN q Gladys K. Breeden
i DATE ISSUED: /-N 2 1/2009.
Deputy State Registrar .
This copy is not valid unless prepared on paper with an engraved border
a
STATE` OF WYOMING
EXHIBIT" ,::DEPARTMENT OF HEALTH 1
Q06174
?0::02- ~bq3
STATE OF WYOMING ^
DEPARTMENT OFIIEALTH D"' 01 L 7
LOCAL FILE NUMBER: : i:: <,.CERTIFICA'TE OF DEATH STATE FILE NUMBER
First Name
Mitldk Name,
Last Name '
Tyrel
Richard
Ashment
Date of Death
Place of Death: City
PhtcaofDeath: County
November 22 2008
Freedom
Per Vital Statistics Services Rules and:Regulations C ter5 Seetion3(e); Ws aftidavitwill serve as the supplemental report
and is to be completed by the Coronet, Deuuty Coroner, 'or Phvsiclan who signed the certificate iNLY
Item
Information as slated on the original Death Certificate.
Information as it should read after completion of investigation.
Number
2 a
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Com do pv~r asa ~ 'u
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Yes
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I HEREBY DECLARE UNDER OATH T14AT
DATE FILED / e)l /20 9 . I .
3 915 13 4!5~
/t This is a true certification of the document on file in the office of Vital
~Z 4 Records Services, Cheyenne, Wyoming
S 3i DATE ISSUED: JAN 2 ~~U7 Gladys K. Breeden
' Deputy State Registrar
x T$tCt~
SStc h
11 r, This copy is not valid unless prepared on paper with an engraved border.
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