HomeMy WebLinkAbout950911RECORDING REQUESTED BY
JACK L. COLLISON, P.C.
AND WHEN RECORDED MAIL THIS DEED AND, UNLESS
OTHERWISE SHOWN BELOW, MAIL TAX STATEMENTS TO:
JACK L. COLLISON
A Professional Law Corporation
1610 Oak Street, Suite 106
Solvang, CA 93463
Parcel I.D. No. 35183120400900
STATE OF CALIFORNIA
ss.
COUNTY OF SANTA BARBARA
Affidavit of Death of Trustee
RECEIVED 12/7/2009 at 1:01 PM
RECEIVING 950911
BOOK: 737 PAGE: 594
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Oty594
SPACE ABOVE THIS LINE FOR RECORDER'S USE
PETER G. BURTNESS and PAUL L. BURTNESS, of legal age, being first duly sworn, depose, and say:
1. AUBIE C. BURTNESS, the decedent mentioned in the attached certified copy of Certificate of Death, is
the same person named as Trustee in the certain Declaration of Trust dated July 29, 1993, executed by Aubie C.
Burtness as Trustor.
2. At the time of decedent's death, decedent was the owner, as Trustee, of certain real property acquired by
a deed recorded on December 3, 1993, as Document No. 775415, in Book 341 PR, Page 583, in the Official
Records of Lincoln County, Wyoming, covering the following described property situated in the said County,
State of Wyoming:
Lot Thirty (30) Plat Ten (10), Star Valley Ranch, as said lot is shown on the duly recorded plat of said
Subdivision as filed in the Office of the County Clerk Ex- Officio Registrar of Deeds for Lincoln County,
Wyoming
3. We are the successor Trustees of the same trust under which the decedent held title as trustee pursuant to
the deed described above, and are designated and empowered purs ant to the terms of said trust to serve as
Trustees thereof.
Dated: November 3 2009
Notary Public Commissioned for said County and State
PETER G. BURTNESS, Co- Trustee
PAUL L. BUR ESS, Co- Trustee
SUBSCRIBED AND SWORN TO (or affirmed) before me on this. -3 day of November, 2009, by PETER
G. BURTNESS and PAUL L. BURTNESS, proved to me on the basis of satisfactory evidence to be the persons
who appeared before me.
CAROLE M. BOOTE
1 Commission 1863466
Notary Public California
Santa Barbara County
My Comm rvnires Sep 30, 2013
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I. NAME OF DECEDENT FIRST (0 /0e0)'. 2. MIDDLE 3. LAST (PMlly)
AUBIE CLARINDA BURTNESS
AKA. ALSO KNOWN AS Include (u8 AKA (FIRST, MIDDLE, UST) 4. DATE OF BIRTH mmMd /ocyy 5, AGE Yrs. 1 IF UNDER CNE YEAR
W UNDER 21 HOURS
0. SEX
F
MomM Days
05/11/1912 95
Ibura Mim4es
0. BIRTH STATE/FOREIGN COUNTRY 10. SOGAT SECURITY NUMBER 11. EVER, IN U.S. ARMED FORCE57 12. MARITALSTATURr300P• (N Tate el Dash) 7. DATE OF DEATH
mu/ad/cow B. HOUR (21 Hours)
1555
MN YES X ND um( WIDOWED 01/31/2008
11 EDUCATION-HOW Ve40so. M/15. WAS DECEDENT HISPANICMTINO (AYSPANISHS IN yes, me agnates. m GA) IB DECEDENTS RACE Up to races m° bells1,0(see worksheet
(see earaaheel on Beck)
On NMI)
BACHELOR I S YES: X NO CAUCAS IAN
17. USUAL OCCUPATION Type o aura Mr most of Illa. DO NOT USE RETIRED 1B. KIND OF BU61NE55.08 INDUSTRY I e.17., grocery store, mad oonslruclbn, employment agency. etc.) 19. YEARS IN OCCUPATION
REGISTERED, NURSE HOSPITAL 5
ya
21. CITY.
SOLVANG
22. COUNTY/PROVINCE
SANTA .BARBARA
23, ZIP CODE
93463
24: YEARS IN COUNTY
60
25, STATE/FOREIGN COUNTRY
CA
g 1
25. INFORMANTS NAME( RELATIONSHIP
PAUL L. BURTNESS, SON
27. INFORMANTS MAILING ADDRESS(Etre. and number or 0661 We rWmber, Aly WUI, stale 030'alp)
P0' BOX 347,SOLVANG,CA,93463 I
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2 0.
2Z
Qkk
y d
6 2 NAME OF SURVIVING SPOUSE/SR60' FIRST
29. MIDDLE I
3D LAST (BIRTH NAME'(
3t. NAME OF FATHER/PARENT FIRST
UNKNOWN
32 MIDDLE
33. UST
TORKELSON
31. BIRTH STATE
IL
55. NAME: OF MOTHERJP0RENT -FIR5T
UNKNOWN
36. MIDDLE
97, UST (BIRTH NAME) 't
UNKNOWN
30. BIRTH STATE
US -UNK
Iz
tD
a a r
E
3g, DISPOSITION DATE mMdtl/myy
02/05/2008
40 PLACE OF INA). DISPOSITION
OAK! HILL: CEME'l '2560. BASELINE AVE, BALLARD', `CA' 93463
I
11, TYPE OF DISPOSITION(B)
BU
42 SIGNATURE OP MBAER
LM 1'l/ tG�rw•.a(;0 t
13 LICENSE NUMBER
6062
U ESTp
LOPER FUNERAL SHMRNT
NP LOPER Gf1 PEL
A5 LICENSE NUMBER
FD 1294
A0 SIGN TURE 0 REGISTRAR GISTRA
�t
40
17 DATE 0OWCCyy
02 /04/2008
t.
L
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101 OF
SANTA .YNEE VALLEY 'RECOVERY RES
WS IF ITAL.SPEC
IP ER/OP 00A
.7D
G Q5L SPECIFY
❑IHoswce X HomNLTO
Hpme enl1 Other
t01. COUNTY
SANTA BARBARA
105, FACILITY ADDRESSOR LOCATION' WHERE FOUND (Sire. and number, or lora.bn(
636 ATTERDAG ROAD
100 CITY
SOLVANG
M
O
O
Q N
Zi
107. CAUSE OF DEATH Eller WIN es Ter temUnN bv.nW UGl as
uee ((odes, or 06MlcWbn -.N0 entry 02 0000.Mh 00 NOT e e
cMlaca Ib.N ory, en ventricular RbNIMbR MOW eI WYArp O.s Nbkpy: DO NOT ABBREVMTE
Time Inane) Mew n
DrwIeM ONM
Ma DEATH REPORTED TO CORONER?
YES X NO
eau.
nAt N
IMMEDIATE CAUSE NI TAT)
(6 12Me0u gr mnk7nrewlWg _RESPIRATORY ARREST
MINUTES
In 000111) 'wq
1 °rr IMT)
5250.mplly.W ACUTE BACTERIAL PNEtmtONIA DAYS
N1y
a re
10a BIOPSY Y PERFORMED?
YES X NO
c "'II
s blip b pause
Um A. UM, ICI I(CT)
UNDERLYING
CA 050(010ease or
I
I/O AUTOPSY PERFORMED?.
YES X NO
Initiated the eac h) T
l /1000/ (DTI
reselling In death) UST
112
111 USED IN 02TERWARD CAUSE?
YES X NO
O
OTHER SIGNIFICANT. CONDITIONS CONTRIBUTING TO DEATH. BUT NOT RESULTING IN THE UNDERLYING CAUSE GIVEN IN 107
ALZHEIMER'S DISEASE/
113, WAS OPERATION; PERFORMED FOR ANY CONDITION IN ITEM 107 02 112? (II yes, I M lye, 0(operatbn and date,)
NO
1130, IF FEMALE; 62PONAN7!BLAST YEAR
YES 111 NO UNK
ta
d
A E RUg0�E T O E OTRDYINECAUEAT5UTED D_
Decedent Mended Sou Decedent Last SenAWa
115 SIGN ANs TITLE OF CERTIFIER
I/O, LICENSE NUMBER
G055900"
117 DATE.mm/00 /acyy
02/04/2008
T
S C //O/ Mf�
(A). mmOW /cUW (3) m,n/dd 0010
10/16/1992- r 0173'0/2008`'
115. TYPE ATTENDING PHYSICIAN'S NAME, MAILING ADDRESS, ZIP CODE
'GUSTAVO A DASCANIO,MD,2030 VIBORG ROAD,SOLVANG,93463
O
S'
M
O
eta.' I CENIITY THAI IN MY OPINION DEATH OCCURPEDAT THE HOUR, DATE AND PUCE STATED FROM THE CAUSES STATED.
MANNER OF DEATH Nalvi& *2 40o0 Homicide 06600, Invea determined
(2O INJURED AT WORK?
YES NO UNK
121. INJURY DATE mmMWccyy.
122. HOUR /24000,0/
123, PLACE OF INJURY Iep., 0000,, mar 1 100 0110, wooded area NC .I
t24. DESCRIBE HOW INJURY. OCCURRED (Emus 502/00,, 11001 4/0)
125: LOCATION OF INJURY (Street and number, or location, and cl1y, and ZIP)
122. SIGNATURE OF CORONER DEPUTY CORONER
127. DATE. mMOd /ccyy
128. TYPE NAME, TITLE OF CORONER DEPUTY CORONER
Ill
4
42
2
E
III IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIIHIIIIIIIIIIIIIIIIIIIIIIIIII
6355200
CENSUS TRACT
CERTIFICATI
STATE OF 4 ''ALiFORMA
11111111111111111111111
*0002776
SANTA BARBARA COUNTY
STATE F
ER
20.OECEDENTS RESIDENCE (Street end manlier or boallo0)
636 ^ATTERDAG ROAD"
STATE OF CALIFORNIA SS
.COUNTY OF SANTA BARBARA
PUBLIC HEALTH DEPARTMENT
00u595
CERTIFICATE OF DEATH
USE BLACK INK 015.41143 ERASURES, WHITS TEOUTS OR ALTERATIONS
LOCAL REGISTRATION NUMBER
CERTIFIED COPY OF VITAL 6 RECOR
,DATE ISSUED FEB F 0 2008
This, is a true and exact reproduction of the document officially registered and placed on file
in the 'office of the Registrar, Public Health Department, County of Santa Barbara, California: HEALTH OFFICER
PUBLIC HEALTH. DEPARTMENT'
COUNTY OF SANTA BARBARA, CALIFORNIA
This Copy not valid unless prepared on engraved border displaying seal and signature of Registrar.
1
PBN (Rev) 11106
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