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RECEIVING 951242
BOOK: 738 PAGE: 756
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
AFFIDAVIT OF SURVIVORSHIP
FOR THE ESTATE OF DARREL LANCE ROBERTSON
AFFIDAVIT OF SURVIVORSHIP
FOR THE ESTATE OF DARREL LANCE ROBERTSON
PAGE I OF 6
WE, WILSON ROBERTSON, ASHLEY ROBERTSON and LESLIE
ROBERTSON, being duly sworn under oath, state as follows:
000'56
1. Darrel Lance Robertson, died in Lincoln County, Wyoming, on May 26, 2009.
An original copy of the Certificate of Death of Darrel Lance Robertson is attached hereto.
2. At the time of his death, Darrel Lance Robertson was a resident of Alpine,
Lincoln County, Wyoming.
3. Darrel Lance Robertson was divorced at the time of his death and left we three
children as heirs.
4. Darrel Lance Robertson died intestate. No Last Will and Testament of Darrel
Lance Robertson has been located.
5. Pursuant to Wyoming Statutes 2- 4- 101(c)((ii), we are the heirs at law of Darrel
Lance Robertson because we are his only children. There are no other persons having any right
to the property of Darrel Lance Robertson under probate proceedings in the State of Wyoming.
6. The value of the estate of Darrel Lance Robertson, wherever located, does not
exceed One Hundred Fifty Thousand Dollars ($150,000.00).
7. More than thirty (30) days have elapsed since the death of Darrel Lance
Robertson.
8. No application for appointment of a personal representative for the Estate of
Darrel Lance Robertson is pending or has been granted in any jurisdiction.
[Three separate signature pages follow.]
AFFIDAVIT OF SURVIVORSHIP
FOR THE ESTATE OF DARREL LANCE ROBERTSON
PAGE 2 OF 6
vu fl57
9. At the time of his death, Darrel Lance Robertson had two bank accounts with the
Wells Fargo Bank in Jackson, Wyoming.
10. At the time of his death, Darrel Lance Robertson owned a 1998 Pontiac Grand
Am and a 1995 Ford Pickup Truck.
11. At the time of his death, Darrel Lance Robertson owned assorted personal
property.
12. We hereby request that the debts owed by Darrel Lance Robertson at the time of
his death, and the debts incurred by the Estate of Darrel Lance Robertson be paid in full.
13. We hereby request that the money in the two Wells Fargo Bank accounts be
transferred to Joel Robertson.
14. We hereby request that title to the 1995 Ford Pickup Truck and the 1998 Grand
Am that were owned by Darrel Lance Robertson be transferred to Joel Robertson as his sole
property.
15. We hereby request that the personal property that was owned by Darrel Lance
Robertson be distributed as Joel Robertson sees fit.
16. This Affidavit of Survivorship for the Estate of Darrel Lance Robertson is made
pursuant to Wyoming Statutes 2 -1 -201 et seq.
DATED this J day of December, 2009.
STATE OF Zb/ pp�;j
j
COUNTY OF cc c r
WITNESS my hand and official seal.
CHRISTINA K. ALLRED NOTARY PUBLI
County of State of
Lincoln Wyoming
MY COMMISSION EXPIRES: 4 30 2013
My Commission expires: L
SS.
WILSON ROBERTSON
NOTARY PUBLIC
AFFIDAVIT OF SURVIVORSHIP
FOR THE ESTATE OF DARREL LANCE ROBERTSON
PAGE 3 OF 6
000758
SUBSCRIBED AND SWORN TO before me by Wilson Robertson this 5 day of
December, 2009.
DATED this 17 day of December, 2009.
STATE OF f k tnq
COUNTY OF 1 krytin
SS.
WITNESS my hand and official seal.
CHRISTINA K. ALLRED NOTARY PUBLI
County of a��; r State of
Lincoln Wyoming
MY COMMISSION EXPIRES: 4 30 2013
My Commission expires: 4-,50-0, 013
ESLIE ROBERTSON
SUBSCRIBED AND SWORN TO before me by Leslie Robertson this day of
December, 2009.
NOTARY PUBLIC
AFFIDAVIT OF SURVIVORSHIP
FOR THE ESTATE OF DARREL LANCE ROBERTSON
PAGE 5 OF 6
004) 59
DATED this 3 day of December, 2009.
STATE OF L1.,1 I Cq
J )SS.
COUNTY OF
SUBSCRIBED AND SWORN TO before me by Ashley Robertson this 5day of
December, 2009.
WITNESS my hand and official seal.
CHRISTINA K. ALLRED NOTARY PUBLI
County of State of
Lincoln �e;,',; Wyoming
MY COMMISSION EXPIRES: 4 30 2013
ommiss
on—
a&1 s
NOTARY PUBLIC
AFFIDAVIT OF SURVIVORSHIP
FOR THE ESTATE OF DARREL LANCE ROBERTSON
PAGE 4 OF 6
Decedent:
Name:
Gender:
Date of Birth:
Date and' Place of De
Date of Death:
City Death:
Location:
Additional Decedent
Place of Birth:
Residence:
Marital Status:
Armed Forces:
Name of Father:
Name of Mother:
Informant:
Other Significant
Conditions:
Manner of Death:
Certifier:
Type:
Name:
Address:
Date Filed:
STATE OF V
Darrel Lance Robertson
Male
July 31 1957'
ath:
May 26;;2009
Alpine
130 Greys River Rd
Information:
Jackson, Wyoming
Alpine, Wyoming
Divorced
No
Cecil Wilson Robertson
Francis Evelyn Sperl
Joel Robertson
Coron. er
Michael R Richins, Coroner"
274 N St Box 57,. Grover, WY.831.22
May 27, 2009
411171
rl, This is a true certification of the document on file in the office of Vital
Records Services, Cheyenne, Wyoming.
DATE ISSUED: Thursday, June 04, 2009!
.This copy is not valid unless prepared! on paper with an engraved border.
Eagle Rock Crematory, Idaho Falls, Idaho
Arteriosclerotic Cardiovascular Disease
State File Number:
Social Security Number
Age it the `ime of Death:
Relationship:
Disposition:
Method of Disposition.
Place of Disposition:
Funeral Home or'Facihty:
Facility: Schwab Mortuary, Afton, Wyoming
Cause of Death:
The immediate cause is listed €on the first line followed by any underlying causes.
(a) Insulin Shock
(b) Diabetes
00761
2009 001492
51 years
Brother
20:00 (Approximate)
Gladys K. Breeden
Deputy State Registrar
f LS`�y1�
CERTIFICATIO ITAL RECORD
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