HomeMy WebLinkAbout952367STATE OF WYOMING
COUNTY OF LINCOLN
AFFIDAVIT FOR COLLECTION AND DISTRIBUTION OF
DECEDENT'S PERSONAL PROPERTY PURSUANT TO W.S. 2 -1 -201
SS.
0 00 23 8
I, Julia T. Neuenschwander also known as Julia T. Haderlie being first duly sworn, on oath
depose and state that I am making this affidavit pursuant to W.S. 2 -1 -201, in behalf of myself as
the heir at law and distributee, as hereinafter set forth, and that I make the following statements in
connection therewith:
That Kelly L. Haderlie became deceased on April 8, 1981, in Randolph, Rich County,
State of Utah and was a resident of Afton, Lincoln County, Wyoming, at the time of his
death; that said decedent died intestate; that I am the surviving spouse of the decedent;
that the individual listed in Paragraph 5 below is the only party entitled to the estate of
the decedent in accordance with the laws of the State of Wyoming.
2. That the value of the entire estate of said decedent, wherever located, does not exceed
$150,000.00.
3. That more than thirty (30) days have elapsed since the date of death of the decedent.
4. That no application for the appointment of a personal representative of said decedent is
pending or has been granted in any jurisdiction.
5. The following named distributee is the only party entitled to the estate of the decedent;
that there are no other distributees of the decedent having a right to succeed to any of
the property of the decedent under probate proceedings; and that therefore the following
named claiming distributee is entitled to payment or delivery of all of decedent's
property:
Name
Julia T. Neuenschwander
1
Relationship
Spouse
RECEIVED 3/3/2010 at 10:20 AM
RECEIVING 952367
BOOK: 743 PAGE: 238
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
6. That among the assets owned by said decedent were the following:
39 shares of J. C. Penney Company, Inc. stock, Certificate No. P 20088 ZQ,
dated May 1, 1987.
Attached hereto and incorporated herein by this reference is a copy of said
stock certificate.
That all of the shares listed above are now due and payable to the distributee
named above, Julia T. Neuenschwander.
7. That attached hereto and incorporated herein by this reference is a copy of the death
certificate for the decedent.
8. That the original of this affidavit is being filed of record in the office of the County Clerk
of Lincoln County, Wyoming, in compliance with W.S. 2- 1- 201(c), as amended.
EXECUTED as of this 1st day of March, 2011.
Subscribed and sworn to before me by Julia T. Neuenschwander aka Julia T. Haderlie, this
1st day of March, 2010.
Witness my hand and official seal.
My commission expires: Y ay 1 11.
2
NOTARY PUBLIC
000239
Q s.ed
Julia T. Neuen hwander
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NAME OF DECEDENT FIRST MIDDLE LAST
Kelly "L" HADERLIE
SEX
3 Male
PACE (While, Black Am. Indian ale.)
Specify
White
ATE PILE NUMB E3
DATE OF DEATH (Mo., Day, w)
April 8, 1981
WAS DECEDENT OF SPANISH ORIGIN? YES NOY11 yew .nmcale lope'
M eaiea0 Puerto Rion Cube Omar III Whet. wordy,
DATE OF BIRTH (No Oa,. Yawl
March 9, 1947
AGE (LU1
Birthday)
7. 34 7,.,
IF UNDER I yew
(FLOWER 54 HOURS
Monlne Days
Mourn Mlnultl
BIRTHPLACE (Scale or foreign
e country; Wyoming
CITIZEN 01 what cnuno
E USA
Morin., V J Di.u,cpl
+O N"vor Werowgl
Mar,ter Orr
EDUCATION— (Spaclfy only hignesi g .d. completed)
Elementa w Secondary (013) College +5 or 1
I 1 3
SOCIAL SECURITY MUMMIES
USUAL OCCUPATION (Glyn Mind 01 work do a ,lunng muff of 'KIND OF BUSINESS OR INDUSTRY
wOMrnp Isle, even 11 retired./
I� Inspecto i Wyo. Dept.of Agricultug4
NAME of surviving spouse III, *IM, enter N NOM game.)
Julia Ti tensor
NAME OF FATHER
1S LaMar Fredrick Haderlie
MAIDEN NAME OF MOTHER
1e Edith Weber
Ws, decadent ever In U.S.
Armed Forces?
YES N016
-J
I
USUAL RESIDENCE -43341 and number w location and hp c000l 'INSIDE CITY LIMITS,
Box 708 I YES Y NO 1,,
34. )134
NAYS A MAILJNO ADDRESS OF INFORMANT
Mrs. Julia T. Faderlie
Box 708
,efton, Wyoming 83110
C ITY OR TOWN COUNTY STATE
tl Afton i, Lincoln 1 134 Wyoming 83110
.t' F
NAVE 01 hospilal, nuramp lwme w O mer mslnunon where death outgrew n, pauenr CITY OR TOWN 'COUNT!
I II a
ouaitl an inelime Iw Alec dd+ I paper„ 1
L oganegiona l Hos ,OnJ
pi tat /U! ,ob Logan L Cac 1 I'
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MEDICAL EXAMINER: I hereby certify Thal loth* Oriel 01 my knowledge IM death occurred at the now. !PHYSICIAN OR MEDICAL EXAMINER SIGNATURE III 1YE of dam! (Ye M. 3(000)
dale and place Waled ebove born 1M causes staled blow Dried on eam ro d J
meln O+ andnoi t X 1
inveshga+ron of Ib ceCumsaneee. p I 164,—"r 1 7 16
Dece0M1 was pro"du"ced dead 31 HOLR 7 DATE p p 1;.14 n 44.4.44.- t •Ja. 11 cal
P HYSIC I AN: I hereby earn)y 1131 lO IM oil 01 m owledge 1110 034 FIE
1h Gneurre0 al ERTIA'S m and r JTyoa or 1011 'DATE S10NEDI(Mo., Y. Tea)
life now. owe ono plan Waled Whs. hum Ina causes staled Oa1ow. mar alienate) rho I
011•") last 34w IM 34134'nr ane On a a/�` 12 0 Hug h D. Hammond, M.D. 1
O '0'. ark mom" I 3+f. L (q
01
I n canned DY m34i oaaminer, was Bea upon W to hrm> YE 5 I N N Yos.
en ter Ine dale end now reported 133 hourclocq
HOUR /03 M0. //PA L. rJA 4 1 Y ,LE 1 19.
CEPTIFIER'S oddinsa ano HD c H NUMBE
CENSE
'LICENSE NUMB ER
550 East 1400 North Logan, Utah (i/ cu
R
11L
►R
Bunsl Enlom1enr 10ATE
Remove. Omnraron 1 4/11/81
other I 33B
SIGN UPI• Fullers Of reclw
vra
3e
FUNERAL HOME— Noma, adore. and Men. number
..HALL MOR IARY- IAgar1, Utah #179
NAME AND LOCATION OF CEMETERY OR CREMATORY
Be dford, Wyoming Cemetery
LOCAL RE ute
J I G
Ie eccePt00 la registration by
''A'PR 0 9 1981
1./SE
11TH
Syr
P ART I. DEATH WAS CAUSED BY 101ATE
MME
CONDITIONS IF ANY car
CAUS /t c :E n1,1 ,I1 0.. l.n ejo, A R enrl P.1 O
Interval b lwn onset 0 0341
rl _t L s r: 1 f
L L 9 1 LvW d
WHICH GAVE RISE TO DUE
THE IMMEDIATE CAUSE ID)
TAI. STATI THE UN
.d (i
'0, OR AS A ONSEOVENCE 0 tlnlerval between on3411Ad 0 D4 ee
DERIVING CAUSE LAST. DUE TO. OR AS A CONSEQUENCE OF 'Interval be wtl0 tinsel end 0341h
ICI
PART II. OTHER SIGNIFICANT CONDITIONS— CONTRIBUTING 10 DEATH. 001 NOT RELATED 70 THE
IMMEDIATE CAUSE GIVEN IN PART 1
30
AUTOPSY (F YES,w53 Indindaconaid.,
YES NO m Oalermininq uu34 OI dim,
JIr. Idle YES It NO r:.
z
cc cr 0
*00013,1) V A,” .,r ,l,rnnn
Streele
Momre,0, A b• .r 0.e„err
cculOnnl r`i,,ynx,.i■
DA1E r,l lnl a„ 1101 vow SHOE OF lNJ1/RY
I 1 r'r
y� I
73a k_ J (1. r .S
INJURY AT I ORR?
YFS O
PLACE OF INJURY (Speclly home, farm, 1ec10ry tree a y.
real, orrice betiding', e1C.I
sI e"1 r 1_ k-0
LOCATION OF INJURY STREET AND NUMBER OR LOCATION AND CITY OR TOWN fl now 1,0,1: 0r bury to
p J y .�-yL I I RI
]34. s1!I Ct. CI1 /n,6x. ,g 0 1. ..�n n om• 8140
Were ra0Oral"ly reels do a nor
drugs Or Ioie enem, als>
31. YES r N0.
Wale lab0relory lest.
done for alcohol/
Se. YES gF N0 t"
C k
DESCRIBE HOW INJURY 0 CUR ED tecw eueon of wenrs rhIsh .011.0 in r0) TU
NAR OF IHJU1 f.
SHOULD BE ENTERED IN ITEM 391 A 1•L C'f L_ #.-71--. r0 st 4 j r•“ c /l pri ay o 4 DO 47 .4V.
CkII rte' o h Pi:// (1 Vet'/
I1 cooler vehicle ecci0enr, specify
it decedan vat, driver. pfssenpw
ppe0tllnan /JA
tla
c0. ACr. IOCAI FILE NUMBER D 47,3
rn This is to certify that this is a true copy of the certificate on file in this office. This certified copy is
issued under authority of Section 26 -15 -26 of the Utah Code Annotated, 1953 as Amended.
re
Dale Issued: OR p r1' d I
Q, i W L,' D Y /J L cY.
G At1L'ZG�L7
Q COUNTY BEAR RIVER D {STRICT John E. Itrnrl:rl l
NTH DEP I EC'(�; OF VITAL SIA iC5
REGISTRAR JOHN C. BAILEY M. D.
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DEPARTMENT OF HEALTH
N.kkl#LkllL/100,00 11, k
WARNING: 11 I5 ILLEGAL TO OUP
11171
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CERTIFICATE OF DEATH
STATE OF UTAH DIVISION OF HEALTH