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HomeMy WebLinkAbout951211RECORDING REQUESTED BY: ROBERT MICHAEL WAY, ESQ. WHEN RECORDED MAIL TO: ROBERT MICHAEL WAY, ESQ. DEASON LAW FIRM 242 W. 28 Street, Suite A Yuma, AZ 85364 State of Arizona s.s. County of Yuma Dated: August 25, 2009 AFFIDAVIT OF DEATH OF TRUSTEE 000673 RECEIVED 12/21/2009 at 1:50 PM RECEIVING 951211 BOOK; 738 PAGE: 673 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY SPACE ABOVE THIS LINE FOR RECORDER'S USE RUTH A. DeBLOOIS, Successor Trustee, of legal age, being first duly sworn, deposes and says: 1. The Trust known as the ROGER CLARK DeBLOOIS FAMILY WEALTH TRUST, executed on December 16, 2008, is a valid and existing trust. 2. The name of the Trustor of the Trust is: ROGER CLARK DeBLOOIS. 3. The name of the previous trustee of the Trust is: ROGER CLARK DeBLOOIS. 4. I am the currently acting Successor Trustee. 5. The Trust has not been revoked, modified or amended in any manner which would cause the representations contained herein to be incorrect. 6. The legal description of real property in the Trust is attached hereto as Exhibit A. 7. I became the Successor Trustee upon the death of the Trustee, ROGER CLARK DeBLOOIS. Attached is the certified copy of ROGER CLARK DeBLOOIS' Arizona Death Certificate. 8. Attached as Exhibit B are copies of excerpts from the original Trust document pertaining to the succession of the undersigned as Successor Trustee. RU A. DeBLOOIS, Successor Trustee State of Arizona s. s. County of Yuma On August 25, 2009 before me, ()_E,/ j,'/j/& 1 8.04 (fi S personally appeared RUTH A. DeBLOOIS, Successor Trustee, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged to me that she executed the same in her authorized capacity, and that by her signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of Arizona that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature 000674 EXHIBIT A LOT 182 of STAR VALLEY RANCH RV PARK PLAT 1 as platted and recorded in the official records of Lincoln County, Wyoming, together with all improvements thereon situate. Subject to any reservations, restrictions, covenants, conditions and easements of record. EXHIBIT B OOC67G ROGER CLARK DeBLOOIS FAMILY WEALTH TRUST Article One Creation of My Trust Section 1. Parties My Trust Agreement, dated December 16, 2008, is made between ROGER CLARK DeBLOOIS, the Trustor, and the Current Trustee as appointed under Section 4 of Article Three. Section 2. Trust Name My Trust may be referred to as the: ROGER CLARK DeBLOOIS FAMILY WEALTH TRUST, dated December 16, 2008. The formal name of my Trust and the designation to be used for the transfer of title to the name of my Trust is: ROGER CLARK DeBLOOIS, Trustee, or his successors in trust, under the ROGER CLARK DeBLOOIS FAMILY WEALTH TRUST, dated December 16, 2008, and any amendments thereto. Section 3. Trust is Revocable My Trust is a revocable trust. My Trust is a grantor trust under the provisions of Sections 673- 677 of the Code. My Social Security Number is and may be used as the tax identification number for my Trust. Section 4. Family Members All references to "children" are to (i) all of the children so identified in this Section 4 (subject to the exclusion of any child under subsequent provisions of this Section 4) and (ii) any children conceived or adopted by me subsequent to the execution of this instrument and prior to my death. a. Marital Status I am presently unmarried. 1 -1 Section 1. Definition Article Three Trustees 000677 All uses of the word "Trustee" in my Trust Agreement shall be deemed a reference to the person or entity then serving as Trustee and shall include alternate Successor or Co- Trustees (if multiple trustees are serving), unless the context requires otherwise. Section 2. Trustee's Resignation Any Trustee may resign at any time without court approval by giving written notice to me if I am living and competent. If I am not then living and competent, written notice shall be given to my next Successor Trustee; or if there is no next Successor Trustee, to the beneficiaries then entitled to receive income or principal distributions under my Trust Agreement or their respective Personal Representatives, or if any of such beneficiaries are then minors, to the persons having the care or custody of any such minor. Such resignation shall be effective upon the appointment of a Successor Trustee. Section 3. Trustee's Removal Any Trustee may be removed under my Trust Agreement as follows: a. While Alive and Competent While I am alive and competent, I shall have the right to add a Trustee, or to remove or replace any other Trustee appointed under my Trust Agreement at any time without cause. b. Removal by Other than Trustor After my death or incapacity, a majority in interest of the beneficiaries then entitled to receive income or principal distributions from a separate trust, or their respective Legal Representatives, shall have the discretion and power to remove any serving Trustee of such separate trust at any time for cause, as defined under Section 18 of Article Eleven. The serving Trustee who is being removed for cause may accept such removal, or may, within thirty days of receiving written notice of removal, petition a court of competent jurisdiction for a determination as to whether sufficient cause exists for such Trustee's removal and shall continue to serve until otherwise ordered by such court. A majority in interest of the then living income beneficiaries of any trust hereunder (in the case of a minor beneficiary, the legal guardian or natural parent of the minor beneficiary) shall have the right to remove any corporate trustee of such trust by a written instrument duly acknowledged and delivered to such 3 -1 corporation. Concurrent with the exercise of this right, the income beneficiaries (in the case of a minor beneficiary, the legal guardian or natural parent of the minor beneficiary) shall appoint a successor corporate trustee by a written instrument duly acknowledged and delivered to the corporation appointed successor trustee; provided, however that such corporation must be a trust company or bank possessing trust powers organized under the laws of the United States of America or one of the states thereof and it must have under its management a minimum of One Hundred Million Dollars ($100,000,000) in trust assets. Upon receipt by the removed corporation of the written notice of acceptance of appointment by the successor corporation, the removed corporation shall forthwith surrender and deliver to the successor corporate trustee all of the assets in the trust estate, and the trusteeship of the removed corporation shall terminate. c. Notice to Removed Trustee Unless a serving Trustee has petitioned, or will petition within thirty days, a court as provided in the paragraphs above, written notice of removal under my Trust Agreement shall be effective immediately when signed by the person or persons authorized to make the removal and delivered to my Trustee personally, or within three business days after mailing by certified mail, return receipt requested. The written notice removing a Trustee shall identify the Successor Trustee appointed pursuant to the other provisions of this Article. d. Transfer of Trust Property Unless petitioning the court as provided above, the Trustee so removed shall promptly transfer and deliver to the Successor Trustee all property of my Trust under the removed Trustee's possession and control. 00067P Section 4. Appointment of Trustees I shall serve as the Current Trustee of my Trust. If for any reason I am unwilling or unable to serve as Trustee, my first Successor Trustee shall be RUTH A. DeBLOOIS. If for any reason RUTH A. DeBLOOIS were unwilling or unable to serve as Trustee, then RICHARD KIRSHBAUM shall serve as Successor Trustee. If for any reason all of the above named Successor Trustees are unwilling or unable to serve, then a Successor Trustee shall be appointed as provided under Section 5 of this Article. Section 5. No Designated and Qualified Successor Trustees If at any time there is no Trustee acting under my Trust Agreement and there is no person or entity designated and qualified as a Successor Trustee, a majority in interest of the beneficiaries then eligible to receive distributions of income or principal under my Trust Agreement, or their Legal Representatives, shall appoint a Successor Trustee. If any trust existing under my Trust 3 -2 so. 000679 Agreement lacks a Trustee and no successor is appointed pursuant to this Article, the vacancy shall be filled by a court of competent jurisdiction. Section 6. Rights, Responsibilities and Duties of Successor Trustees Other than amending or revoking my Trust, or appointing or removing a Trustee, a Successor Trustee shall have the same rights, powers, duties, discretion and immunities as if named as an Current Trustee under my Trust Agreement. No Successor Trustee shall be personally liable for any act, or failure to act, of any predecessor Trustee or shall have any duty to examine the records of any predecessor Trustee. A Successor Trustee may accept the account rendered and the property delivered by, or on behalf of, a predecessor Trustee as a full and complete discharge of the duties of the predecessor Trustee without incurring any responsibility or liability for doing Section 7. Co Trustee's Responsibility for Acts of Other Co Trustees No Co- Trustee shall be responsible for the act, omission or default of any other Co- Trustee without actual knowledge thereof. Section 8. Special Co Trustee Provisions The function of the Special Co- Trustee is to protect the financial resources controlled and governed by my Trust and the interests of the beneficiaries. a. Appointment of Special Co- Trustees In the event a Special Co- Trustee is needed to act, the first Successor Trustee who is independent within the meaning set forth in Code Section 672(c) shall act as Special Co- Trustee, or if no such individual is available, a majority of the Successor Trustees designated under Section 4 of this Article, shall have the right to designate by written instrument a Special Co- Trustee who is qualified, as defined in Paragraph b. hereunder. b. Qualifications of Special Co- Trustee A candidate for service as Special Co- Trustee must be independent and may not be related to, or be subordinate to, any member of my family or the family of any direct or indirect beneficiary. Any person who provides professional services to any one or more members of my family is not per se a prohibited person if compensation for services rendered constitutes, excluding compensation for service as Special Co- Trustee, two percent or less of his, her or its income during any calendar year. 3 -3 c. Special Co- Trustee May Not Serve as Trustee Except for the special fiduciary authority given to a Special Co- Trustee, a Special Co- Trustee, including any Successor Special Co- Trustee, may not serve as a Trustee. This is in keeping with my intent and purpose that the Special Co- Trustee's only interest will be to protect the financial resources governed by my Trust Agreement and the beneficiaries thereto. It is further provided and required that the Special Co- Trustee may never have any personal financial interest in any property of my Trust or in the outcome of any transaction or any business by or for my Trust other than the payment of a fair and reasonable compensation for his, her or its services as the Special Co- Trustee. The responsibilities of the Special Co- Trustee shall be limited to the exercise of the power, duty, or discretionary authority as provided throughout my Trust Agreement. Said Special Co- Trustee shall not be concerned with, nor shall have, any authority with respect to any other aspects of administration of my Trust Estate. d. Special Fiduciary Authority of Special Co- Trustee In addition to the authority specifically given to the Special Co- Trustee under various provisions throughout my Trust Agreement, the Special Co- Trustee will have the authority to perform any one or more of the following functions to the extent that the discretionary authority of my Trustee to perform a function might constitute an act of self dealing or might jeopardize the tax status of my Trust. 1. Valuation The value of certain property of my Trust may not be readily ascertainable, for example, real estate and securities held in a closely held corporation, partnership, limited liability company or other investment or business organization. Marketable securities shall be included in this category if and to the extent that market quotations are not readily available for trades of the security in an established securities market. Whenever my Trustee's right to determine the value of this kind of property may be self serving or may produce a possible conflict of interest or adverse taxation issues, the Special Co- Trustee is to value the property of my Trust. 2. Voting Rights Whenever my Trustee's right to vote an equity interest in a corporation, partnership, Limited Liability Company, investment trust or business trust or other entity may be interpreted as self serving or may produce a possible conflict of interest or adverse taxation issues, the Special Co- Trustee will have the right to vote the equity interest. Voting rights will include decision making 3 -4 000680 authority with regard to the sale, exchange, or liquidation of any equity interest in .a closely held corporation, partnership, Limited Liability Company, investment trust or business trust or other entity. 3. Life Insurance Policies Whenever my Trustee's rights as to the control and maintenance of a life insurance policy or any interest in a life insurance policy could result in the inclusion of the proceeds of the policy in the estate of the insured for tax purposes, decision making with regard to a life insurance policy or interest in a policy is to be made by the Special Co- Trustee. 4. Discretionary Distributions of Trust Income and Principal To the extent my Trustee has the discretionary authority to make distributions of income or principal to or among beneficiaries or to retain all or any part of the income, and to the extent this discretionary authority may result in, or appear to be, a conflict of interest or an opportunity for self dealing or may produce adverse tax consequences, the Special Co- Trustee is to make all decisions with regard to the discretionary distributions of income and principal and the retention of income. 5. Gifting Powers To the extent my Trustee has the authority to make gifts of income or principal to such Trustee and to the extent this authority to gift may result in, or appear to be, a conflict of interest or an opportunity for self dealing or may produce adverse tax consequences, the Special Co- Trustee is to make all decisions with regard to any gifts made to such Trustee. 6. Property Located In Another Jurisdiction The Special Co- Trustee may appoint an Ancillary Trustee to control and administer property located in another jurisdiction. 3 -5 000681 7. Amendment Powers A. Changes in Law or Beneficiary Circumstances The Special Co- Trustee may, from time to time, amend my Trust Agreement, including any sub -trust created hereunder, to address changes in federal or state law, or other circumstances which may affect my Trust and its beneficiaries or to delete provisions rendered obsolete due to changes in law or beneficiary circumstances. In exercising such power, the Special Co- Trustee shall consider the overall best interest of the present and future beneficiaries and shall be guided by what the Special Co- Trustee believes, in his or her discretion, would have been my intent in light of such changed circumstances. 8. Repeal of Federal Death Taxes In the event of the repeal of the federal estate tax and generation- skipping transfer tax (as currently set forth in Chapters 11 and 13 of the Code) after my death or disability, the Special Co- Trustee may terminate my Trust Agreement, or any sub -trust created hereunder, by distributing the trust principal to my living descendants in whatever proportion the Special Co- Trustee deems appropriate. In exercising such power, the Special Co- Trustee shall, in addition to the factors set forth in the preceding paragraph, consider the following: A. The enactment of any federal income, capital gains or other tax which would impact adversely on, or offset, the tax benefits of any proposed trust or sub -trust termination; B. The benefits afforded to the beneficiaries by the continuation of my Trust, such as protection against the claims of judgment creditors, divorcing spouses, and insulation from the reach of governmental agencies; and 3 -6 000682 e. Consultation C. The likelihood of re- enactment of a federal estate, gift, or generation skipping transfer tax or comparable tax which would subject my Trust Estate to the imposition of such tax or taxes in the hands of, or upon lifetime or testamentary transfers by, the beneficiaries to whom my Trust Estate would have been distributed upon termination. 006683 My Trustee is authorized to consult with the Special Co- Trustee as to any matter relating to the investment of assets, discretionary distributions and the use of principal, tax matters, dealings with the beneficiaries, and any other matter relating to the administration of my Trust in keeping with the objectives and purpose of this Trust Agreement. My Trustee will not be liable for any act or omission to act if acting according to the written instructions of, or with the written consent of, the Special Co- Trustee. f. Accounting and Transaction Reports The Special Co- Trustee will have the authority to receive and review any and all accounting reports, records, tax returns, transaction reports and ownership records concerning my Trust. All records of my Trust must be open for inspection at all reasonable times by the Special Co- Trustee. g. Resolution of Disputes The Special Co- Trustee may unilaterally resolve any dispute, claim or conflict between beneficiaries, including those who have, or claim to have, a present or future interest in property, between a beneficiary and a trustee, or between trustees. Such resolution shall be binding on all parties to my Trust and shall not be subject to review. No one may file or instigate a claim in a court of law without first submitting the claim to the Special Co- Trustee for resolution together with detailed supporting information and a detailed supporting memorandum of law. In the event the Special Co- Trustee finds the supporting information or memorandum of law insufficient, the Special Co- Trustee may request such additional information as the Special Co- Trustee reasonably feels necessary to resolve such claim. The Special Co- Trustee may employ, and may act upon the advice of, legal counsel in making a resolution of any issue of fact and law. The Special Co- Trustee may submit the claim or dispute for mediation and/or binding arbitration. Subsequent to his or her review, the Special Co- Trustee may give any claimant the authority to file and maintain an action in a court of law. The granting of such authority by 3 -7 the Special Co- Trustee shall in no way nullify the "No Contest" provision provided under the "Other Trust Provisions" of my Trust. Whenever a dispute, conflict, or claim involves an interpretation or construction of my Trust Agreement, the Special Co- Trustee may file an action in a court of competent jurisdiction for the interpretation and construction of such Trust Agreement, or the Special Co- Trustee may instruct my Trustee to do so. h. Business Judgment The Special Co- Trustee is permitted and authorized to exercise "Business Judgment" in the course of service in the capacity of Special Co- Trustee. The Special Co- Trustee will not be liable for any act or omission to act unless it is conclusively established that the act or omission to act was motivated by an actual intent to harm my Trust or a beneficiary of my Trust or is an act of self dealing for personal pecuniary benefit.. My Trust will pay or reimburse the costs of defending and/or settling any claim made against the Special Co- Trustee unless it is conclusively established that the Special Co- Trustee's conduct was motivated by an actual intent to harm my Trust or a beneficiary of my Trust. All provisions of my Trust Agreement that limit the liability of my Trustee will likewise apply in limiting the liability of the Special Co- Trustee. i. Authority of Successor Special Co- Trustee A Successor Special Co- Trustee will have all of the authority and duties of the Special Co- Trustee by original appointment, but will not be responsible for the acts, or omissions to act, of his, her, or its predecessor. j. Compensation A Special Co- Trustee may receive reasonable compensation as an expense of administration. The Special Co- Trustee is entitled to reasonable reimbursement for expenses and costs incurred on behalf of my Trust. Payment of compensation shall be from the funds of my Trust. k. Bond Unless otherwise required in written articles of appointment, the Special Co- Trustee will serve without the requirement of bond or other security. 3 -8 000684 4 I have executed my Trust Agreement on the date set forth on the first page of my Trust Agreement. I certify that I understand my Trust Agreement and that it correctly states the terms and conditions under which my Trust Estate is to be held, managed and disposed of by my Trustee. I approve this revocable living trust in all particulars and request my Trustee to execute it. Trustor and Trustee: RO i R CLARK DeBLOOIS STATE OF ARIZONA COUNTY OF YUMA r The foregoing instrument was acknowledged before me on this December 16, 2008, by ROGER C ARK DeBLOOIS. tary u •he Prepared by: Lawrence L. Deason Deason Law Firm 242 W. 28th Street, Suite A Yuma, AZ 85364 (928) 783 -4466 FAX (928) 343 -9586 www.deasonlaw.com Execution S S 11 -23 f,.,, "OFFICIAL. SEAL" Sharayah Whitfield 4 Notary Public-Arizona Yuma County M Commission =s 2012 0006195 _y S,r7CJV,:: CERTIFICATION OF VITAL RECORD "VERIFICATION BOX" (HOLD BETWEEN THUMB AND FOREFINGER. OR BREATHE ON IT. COLOR WILL CHANGE TO BLUE AND THEN RETURN.) ORIGINAL STATE COPY NAME OF DECEASED 33. A. FIRST R 8A, COUNTY T, DAY OIS. B. MIDDLE DATE 25. 07 -18 -2009 NAME NERAL DATE SIGNED (Mo., -Day, Year) 31. 07 -13 -2009 NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER S OF CERTIFIER 47B DUE TO OR AS A CONSEQUENCE OF: B. MIDDLE C. LAST DEBLOOIS WAS DECEDENT OF HISPANIC ORIGIN: 4B NO 8B TOWN OR CITY YUMA YEAR AGE (YEARS IF UNDER YEAR F UNDER t DAY LAST BIRTHDAY) 1.405. DAYS HRS. MN. 8A. 88. BC. CITIZEN OF WHAT COUNTRY? SOCIAL SECURITY NO. INTENTIONALLY LEFT 12 BLANK 3 15C OOWWN�OR LI P 15U ZIP CODE YUMA IN CITY LIMITS? SF. NO ON RESERVATIONS 15G. NO C.LAST DE BLOOIS RELATIONSHIP TO DECEASED 22 SISTER IN LAW' CEMETERY OR CREMATORY NAME/LOCATION.. 26.SUNSET VISTA CREMATORY, YUMA, ARIZONA STREET ADDRESS CITY AND STATE 11357 E. 40TH STREET.YUMA, AZ TO THE BEST OF MY KNOWLEDGE, DEATH OCCURRED AT THE TIME, DATE p5Z) PLAGE AND DUE TO THE CAUSE(S) STATED. SS SIIG RE RUBEN CORIANO, M.D.; HOUR OF DEATH 32. 2148 SEX RE RUBEN IF YES, INDICATE MEXICAN, SPANISH, PUERTO CUBAN, ETC. 4C. 6C. HOSPITAL OR (IF RESIDENCE GIVE INSTITUTION 13276 E 54TH ST MARRIED, NEVER MARRIED, WIDOWED, DIVORCED (SPECIFY) B WIDOWED 14A. ENGINEER HOW LONG IN ARIZONA? 3.:367' a R h6.' EAr.. PREVIOUS STATE OF RESIDENCE 18 INTENTIONALLY LEFT MOTHER'S MAIDEN NAME 20. RUTH ADDRESS 23 13632 E 46TH DR YUMA, ARIZONA 85367 AUTHORIZED FOR CREMATION 40. YES 2 REG. 00 "FIL 9 E N 8 REGISTRAR'S SIGNATURE Y 43.025862 44ANA P TRIGUEROS 47A. IMMEDIATE CAUSE (FINAL DISEASE OR CONDITION RESULTING IN DEATH) (ENTER ONLY ONE CAUSE ON EACH LINE) CARDIOVASCULAR ACCIDENT USUAL OCCUPATION BLANK A. FIRST STREET NO.; DATE OF MONTH DAY DEATH 3. 07 -10 -2009 RTO RICAN WAS DECEASED EVER IN U.S.ARMED 5, YES S ADDRESS) 6D, DEC RE SURVIVING (IF WIFE, GIVE MAIDEN SPOUSE 10. 18A. ELEMENTARY SECONDARY (0 -12) B. MIDDLE CITY AND STATE EMBALMER'S SIGNATURE 27A. INTENTIONALLY LEFT BLANK FUNERAL DIRECTOR or person acting as such (SIGNATURE) VICTORIA BERTUCCI FUNERAL 2BA'DIREOTOR ON 11 BASS OFEXAMNATION AND/OR INVESTIGATION, IN MY OPINION DEATH AT THE TME, OATF'AND PLACE DUE TO THE CALLSE(S) AND MANNER STATED. 34. SIGNATURE. AND TRLE DATE SIGNED_(Mo., Day„ Year) 35. PRONOUNCED DEAD (Mo., Day, Year) 37. ON RE I EN�fIONALLY 451 KIND OF BUSINESS OR 48. ELECTRICA EDUCATION HIGHEST YOUNG HOUR.OF DEATH 38. PRONOUNCED D 38. AT UNKNOWN 188. C. LAS MEDICAL EXAMINER'S SIGNATURE 41 VICTOR M. ALVAREZ �f DATE REC'D IN OFFIC EFT BLANK 40. INTENTIONALLY r 1. RACE ROGE 4A, CAUCASIAN PLACE OF DEATH 6. YUMA DATE OF MONTH BIRTH 7. 01 -16 -1934 STATE AND (H''.not in USA, name coMtry) CITY OF BIRTH t 1 OGDEN,'UTAH USUAL 15A. STATE 158: COUNTY RESIDENCE 15. ARIZONA YUMA STREET ADDRESS OR R.F.D. 15E 13276 E 54TH S FATHER'S NAME A. FIRST g AUDRIAN INFORMANT'S SIGNATURE 21, RUTH A. DEBLO BURIAL, CREMATION, REMOVAL- OTHER ;(Specdy) 24. CREMATION FUNERAL HOME SUNSET VISTA FU 28. HOME NAME AND ADDRE PHYSICIAN, MEDICAL EXAMINER OR TRIBAL LAW ENFORCEMENT: AUTHORITY 39. RUBEN CORIANO,,M'D, 682. S 4TH AVE YUMA, AZ 85364 -3015 DATE REGISTERED 42. 07-22-2009 47. N N Y Z 5 N¢ W y v� t. R oRg 1 4 to PART II. Other sianilicant conditions contr)bUling to death b1A not resulting in the urderlying cause given In Part I DATE OF MO DAY.' YR II4URY 52. HOUR PLACE OF INJURY SPECIFY 58. INJURY AT WORK? 54. WHERE LOCATED? 57. DESCRIBE HOW INJURY. OCCURRE 55. AUTOPSY 49. NO STREET ADDRESS 48. MANNER OF DEATH NATURAL DEATH 51. SUPPLEMENTARY ENTRIES STATE OF ARIZONA DEPARTMENT OF HEALTH SERVICES OFFICE OF VITAL RECORDS CERTIFICATE OF DEATH 1410. OUE 1 U LA; As A COiv3E .:;BNL'c Date Issued: 07 -23 -2009 STATE OF ARIZONA OO 686 DEATH NO. 102 2009 024230 6 2 4, e;t )T This is a true certification of the facts on file with the OFFICE OF VITAL RECORDS, ARIZONA DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA issued under the authority of A.R.S. 36 -341, and by direction of: This copy not valid unless prepared on a form displaying the State Seal and impressed with the raised seal of the issuing agency. PATRICIA ADAMS ASSISTANT STATE REGISTRAR YEAR FORCES? EDENT'S IDENCE NAME) INDUSTRY n L COMP •S. 2 YEA G RADE� S OF COLT FGE COLLEGE )l -4 or s 2 ZIP CODE CERT. NO. 278. CERT. NO. 29B. F1309 OCCURRED E AD (Hour) EFT BLANK APPROXIMATE INTERVAL BETWEEN ONSET AND DEATH WAS CASE REFERRED TO MEDICAL EXAMINER 50, YES CITY OR TOWN STATE 8. S8 €823 b�f i+ ANY ALTERATION OR ERASURE VOIDS THIS DOCUMENT Arizona Department of Health Services