HomeMy WebLinkAbout872511FILED:
STATE OF WYOMING
COUNTY OF FREMONT
SS.
RECEIVED
LINCOLN COUNTY CLERK
872511 °IArr -s hprr
Subscribed and sworn to before me this day of MO 12->\ 20 01
(Office u,se only)
KEMMERER, WYOMING L,
BOOK 6 pR PAGE 1 4
r
Notary Pub fc
A} FIDAVIT
1, Shari M. Grissom Being of lawful age and being first
duly sworn, deposes and states as follows:
1. That thirty (30) days have elapsed since the death of Danny D Grissom
(hereinafter referred to as Decedent) who died on
the 21st day of July 2001 A copy of the death certificate
of the Decedent is attached hereto.
2. That the value of the entire estate of Decedent, wherever located, less liens
and encumbrances, does not exceed Seventy Thousand Dollars. ($70,000.)
3. That no application for appointment of a Personal Representative of the
Decedent is pending or has been granted any jurisdiction.
4. The following named persons are entitled to payment or delivery of the
property of the Decedent, including payment of capital credits in the name
of the Decedent on the books of High Plains Power, Inc. (formerly
Riverton Valley Electric, Inc. and Hot Springs R.E.A.), Riverton
Wyoming, to wit:
Relationship
Name Age A to Decedent
Shari Grissom 41 PO Box 5207, Etna, WY 83118 spouse
Caitlin Grissom 5 same daughter
Zachary Grissom 1 same
List additional on back of form
Right to succeed to the property under probate proceedings.
5. Affiant makes Affidavit pursuant to the provisions of Section 2 -1 -201,
Wyoming Statutes, 1977, as amended.
DATED this day of MLLt 200
Affiant Signature
r ylOryt,oW,:a.�o.te
ONNS 1 NOTARY PUBLIC
COUNTY OF STATE OF
LINCOLN (t;? WYOMING
W COMPASSION EXPIRES
CERTIFIER
CAUSE
OF DEATH
CERTIFICATION OF VITAL RECORD
DISPOSITION
..1444
T
f a ANY ALTERATION OR VOIDS THIS CERTIFICATE
H r,. o F P r r: I'
�V1
DECEDENT
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7a FAd1rY NAME (0 no4 he8IWba sA• me .[ridttwia;.
U. S. 89 MILEPOST45
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WISCONSIN
ACCIDENT SCENE
Ni COUNTY OF DEATH
LINCOLN
TYPE
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PERMANENT
FOR
INSTRUCTIONS
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HANDBOOK
INFORMANT
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IN-RESIDENCE STATE
WYOMING
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(EoeoNy r« r; NO
1 7. FATHER'S NAME FM
EARLON
194.142011144222-14445 r.•SN)
SHARI GRISSOM
+/n MAENQ ADDRESS-
BOX 52Q7'
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DIRE TO AEA CONSEQUENCE OAI
DEPARTMENT OF HEALTH
STATE OF WYOMING
DIVISION OF HEALTH AND MEDICAL SERVICES
CERTIFICATE OF DEATH
a r AOE.w IN=
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DUE TO (0a AS A CONSEQUENCE OR:
CUE TO (OR AS A CONSEQUENCE OF):
POUT l men SxDEFCANT CONDITETNSCrddaa o *Ibulie r ON PA not Wed to caw gloat N PMT I
1
304 DATE OF INJURY
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JETNOCEMETE
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U. S. HIGHWAY 89
This is a true and exact reproduction of the document on file In the office of Vital
Records Services, Cheyenne, Wyoming.
DATE ISSUED: Aur, 1
Ma UNDER 1 YE)12 So. tN 11UAY
Moan DM'.. lb" ►aAM
E
134 STpEE1
COUNTS%:
Sod
wti cr4 fro 0 1
SSG OATS necovso Sr REDN711M (Ab MY. Y..)
Lucinda McCaffrO
Deputy State Registrar
This copy is not valid unless prepared on paper with an engraved border displaying the date, seal and sIgnature of MO Deputy State Registrar.
148
2:100 002021
STATE FEE NUMBER
3. DATE OF /Ma Day. 12.)
L GATE ORINRIN (Ma Da. Yr.)
.IKNNSS OR enU STRY
LOYED
961 CLARK LANE
Mellen Swam
0Lt1ICDON
WYOMING
FOURTH AVE., AFTON
=NUR of DEATH
4114 iriu444.4-
STATE
23s. PRONOUNCED DEAD (Mr,)
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Oat ad Den.
M I'
E7. AUTOPSY Nomity O. WAS CASE REFERRED TO CORONER
pea MI) (sMd rie r ro)
Not MOW NOW INJURY OCCURRED
'Nca'J aN ca //t S lo./
3011.' LOCATION PHA and gram or Runl Rod, Puma, COY or Torn 2444)
MILEPOST 76.85