HomeMy WebLinkAbout956522AFFIDAVIT SEEKING DISTRIBUTION PURSUANT TO
§2 -1 -201 OF THE WYOMING STATUTES
STATE OF COLORADO
SS
COUNTY OF A �i,�P/��/o�
I, Craig Fahringer, being first duly sworn, upon ,my oath, depose and say:
1. I am the son of Alvin Fahringer, and have knowledge of and am coml.,
to testify concerning the facts as stated below.
000673
2. Alvin Fahringer died on May 23, 2010, in Denver County, Colorado.
Attached is a copy of his official death certificate certified to by the State of Colorado,
Department of Public Health and Environment, the public authority with which the
original death certificate is of record according to law.
3. The value of the entire estate of Alvin Fahringer subject to probate at the
time of his death, less liens and encumbrances, did not exceed one hundred fifty thousand
dollars ($150,000).
4. More than thirty (30) days have elapsed since the death of Alvin Fahringer.
5. No application for appointment of a Personal Representative of the estate of
Alvin Fahringer is pending or has been granted in any jurisdiction.
6. Pursuant to the terms of the Last Will and Testament of Alvin Fahringer,
Craig Fahringer and David Fahringer are designated as equal beneficiaries of the
remaining property of Alvin Fahringer. There are no other beneficiaries or heirs of Alvin
Fahringer having a right to succeed to the solely owned assets of Alvin Fahringer
7. I hereby direct that any bank, savings and loan institution, brokerage house,
transfer agent, or any other like depository or insurance provider or agency which is
presented with a certified copy of this Affidavit, pay any deposit or funds or shares in the
sole name of Decedent, Alvin Fahringer together with the interest and dividends thereon,
to the order of Craig Fahringer and David Fahringer.
DATED: this 4 27 day of Ce ,6L 2010.
RECEIVED 11/4/2010 at 11:14 AM
RECEIVING 956522
BOOK: 756 PAGE: 673
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
I, Craig Fahringer, first duly having been sworn on oath, deposes and says: he is
the Affiant in the foregoing Affidavit, that he has read the foregoing Affidavit Seeking
Distribution pursuant to §2 -1 -201 of the Wyoming Statutes and knows the contents
thereof, and the contents of the same are true and correct.
ALLISON OPIELA
A L Notary Public
State of Colorado
My commission expires:
Craig Firinger
000674
The foregoing instrument was acknowledged before me by Craig Fahringer this
7 day of Oc 2010. Witness my hand and official seal.
VA/
CERTIFICATION OF VITAL RECORD
DISPOSITION
CAUSE OF
DEATH
32. MA OF DEATH
Natural Pending
Investigation
STATE OF COLORADO
COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
HOLD TO LIGHT TO VIEW WATERMARK
30.0 NAME, TITLE AND MMAILING AAD CERTIFIER /CORONER (Type /Print)
0 Y 1 14S` r J3/Lt- r7c.' i/ 6 14!<',D a. S ,•5 5 J b Z a k -d
31. NAME OF ATTENDING PHYSICIAN IF OTI4ER THAN CERTIFIER (Type /Print)
Accident
Suicide Undetermined
Manner
Homicide
34. IMMEDIATE CAUSE (ENTER
PART
lal`i
CONDITIONS DUE TO OR AS A CONSEQUENCE OF
IF ANY WHICH
GAVE RISE TO
IMMEDIATE CAUSE (b) 11141.9i-, (-�`41
STATING THE DUE TO OR AS A CONSEQUENCE OF
UNDERLYItJG CAUSE
LAST .Ic) (c)
PART OTHER SIGNIFICAN.TCONDI
II PART 1 (6.g., alcohol abuse, obesity, smoker).
DATE ISSUED MAY 2 3 2010
THIS IS A TRUE CERTIFICATION OF NAME AND FACTS AS
RECORDED IN THIS OFFICE. Do not accept unless prepared on
security Paper with engraved border displaying the Colorado state seal
and signature of the Registrar. PENALTY BY LAW, Section 25 -2 -118,
Colorado Revised Statutes, 1982, if a person alters, uses, attempts to
use or furnishes to another for deceptive use any vital statistics record.
NOT VALID IF PHOTOCOPIED.
STATE OF COLORADO
CERTIFICATEOF DEATH
STATE FILE NUMBER
�9� S i¢Irra ,t.
RONALD S. HYMAN
STATE REGISTRAR
11- 11 II 11111111 I
REV 51/07
000675
1. DECEDENTS NAME (First, Mrddle. Last) 2. SEX 3. DATE OF DEATH (Month, Day, Year)
Alvin Neff FAHR1NGER Male May 23;201
4. SOCIAL SECURITY 5a. AGE Last 5b. UNDER 1 YEAR 5c. UNDER 1 DAY 6 DATE OF BIRTH 7. BIRTHPLACE (City and State or Foreign.
NUMBER Birthday (Y r Mos Days Hrs 50 (Month, Day, Year) Country)
81 February 11, 1929 Elysburg, PA
8. WAS DECEDENT EVER IN 9a. PLACE OF DEATH (Check only one)
U S ARMED FORCES?
®Yes p �NO HOSPITAL' i OTHER:
Inpatient ER /Outpatient 008 I Nursing Home Residence :other (Speedy) 9b. FACILITY NAME (M noriinsfifulion, give 3(30'03 and number) 8c. CITY. TOWN, OR LOCATION OF DEATH 8d. COUNTY OF DEATH
Highline Care Center Denver Denver,
10a DECEDENTS USUAL OCCUPATION --1Ob. KIND OF BUSINESS /INDUSTRY 11. MARITAL STATUS Married, 12. SPOUSE W Wile, give maiden name)
(Dive Smo of work done during most of working life. Never Married, Widowed,
Do not use refired) Divorced Specify)
Machinist Steel Widowed Helen Barjuca
13a. RESIDENCE -STATE 13b. COUNTY 130. CITY,TOWN,OR LOCATION 134. STREET AND NUMBER
Colorado Arapahoe Centennial 6432 South Eudora Way
133. INSIDE 134. ZI CODE 14. WAS DECEDENT OF HISPANIC ORIGIN': 15. RACE: Arderican.Indian, 16.. DECEDENT'S EDUCATION ISpeciiy only highest
CITY ;(Speedy No or Yes If yes, speedy Cuban, Black While, etc. (Specify) grade completed) Elementary or secondary
LIMITS? Mexican. Puerto Rican, etc.). (0 through 12) College (13 through 16 or 17
Yes El No CI Yes
No 801.21 Speedy: White 12
17 FATHER -NA V (First,, Middle. Ga t) 18. MOTHER -NAME (First, M/ddtg, Las? (Malden Name)). 19. INFORMANT -NAME and :relati0nship;30 dedea5ed:
Freeman Fahringer Elizabeth Neff Craig A. Fahringer (Son)
209. METHOD OF DISPOSITION 20b. PLACE OF DISPOSITION (Name of cemetery, cremator or 20c. LOCATION City or TOwn, State
Burial o Ell Cremation Removal )roe, state
other place)
i Donation CI O ther(Speomty) Horan McConaty Crematory Denver, Colorado
219. SIGNATURE OF FUNERAL DIRECTOR OR PERSON ACTING AS SUCH 21b. NAME AND ADDRESS OF FACILITY:.
Horan McConaty Funeral Service /Cremation
1091 S. Colorado Boulevard, Denver, CO ZIP: 80246
229. REGISTRAR'S SIGNATURE 32b. DATE FILED (Month, Day, Year)
.L.�.h.d;�,,..lg� t2 1 itl (d 2010
23. TIM OF DEATH 24. DATE PRONOUNCED DEAD 25. WAS CORONER NOTIFIED?
Month Day an Hour (Yes or No)
3 05. `P .14. .:May' 23 2010 150.5 Yes'
TO BE COMPLETED ONLY BY CERTIFYING PHYSICIAN TO BE COMPLETED BY CORON
26 To thelbest 0l my knowled� ,death occurred at th tim date. and place, and due to 27. On the basis of examination and/or investigation, in myopimon death occurred at the
the causes) and manner. stated time, date and place, and due to the cause(s) and manner as stated:
Signature "J y "2 Signature.
25: DATE SIGNED (Month, Day, Yeai V
29. DATE SIGNED (Month, Day, Year)
May S 2010
33a. DATE OF INJURY
(Month, Day, Year)
Yes No
33e. PLACE OF INJURY -A horde, }arm, street, factory, office
building, ate. (Specify)
R ONLY ONE CAUSE PER LINE FOR I, (b) AND (c),( Do not nIer mode of dying (e.g. Cardiac or Respiratory Arrest)alone.
IONS Conditions contributing to death but not related to cause in
33d. DESCRIBE HOW INJURY OCCURRED
333. LOCATION (Street and Number or Rgial Route Nom
35. AUTOPSY.
(Yea or No)
her, City, County, State)
Interval between onset
and death
Interval beMveen onset
and death
36. IF findings cone/de /ad
in determining cause of death?