HomeMy WebLinkAbout956961WHEN RECORDED MAIL TO:
Jeffery J. McKenna, Esq.
Barney McKenna Olmstead, P.C.
P. O. Box 2710
St. George, UT 84771 -2710
MAIL TAX NOTICE TO:
Gay Lee Guckenburg
355 West Mesquite Blvd., D211
Mesquite, NV 89027
STATE OF NEVADA
COUNTY OF CLARK
AFFIDAVIT OF SUCCESSOR TRUSTEE
RE: DEATH OF TRUSTEE
)ss.
RECEIVED 12/1/2010 at 10:00 AM
RECEIVING 956961
BOOK: 758 PAGE: 121
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
000121
Gay Lee Guckenburg, Sole- Surviving child of James and Mildred LaCoy, Sole
Surviving Successor Trustee of The LaCoy Family Trust dated August 19, 1993, and Sole
Beneficiary of The LaCoy Family Trust dated August 19, 1993 of legal age, being first
duly sworn, declares as follows:
That James F. LaCoy, the decedent mentioned in the attached copy of Certificate of
Death, who died February 26, 2001, and Mildred H. LaCoy, the decedent mentioned in the
attached copy of Certificate of Death, who died July 19, 2009, are the same persons as
James F. LaCoy and Mildred H. LaCoy, Settlors of The LaCoy Family Trust dated August
19, 1993.
That on August 27, 2009, Lorraine A. LaCoy, resigned as the acting Trustee of The
LaCoy Family Trust dated August 19, 1993, thereby appointing Gay Lee Guckenburg and
James Randall LaCoy as Successor Trustees. A copy of the Resignation and Designation
of Trustee is attached hereto.
That James Randall LaCoy, the decedent mentioned in the attached copy of
Certificate of Death, who died May 31, 2006 is the same person as James Randall LaCoy,
Successor Trustee of The LaCoy Family Trust dated August 19, 1993.
000122
Affiant is the Sole- Surviving Successor Trustee named in The LaCoy Family Trust
dated August 19, 1993 and as such has full authority to act as Trustee in all respects.
Affiant is now the acting Trustee of the trust.
Dated: Jo -f, i 0 2010.
SUBSCRIBED AND SWORN to before me this 1 1 day of October, 2010, by
Gay Lee Guckenburg whose identity is personally known to me or proved to me on the
basis of satisfactory evidence, and who, being by me duly sworn (or affirmed), did say that
she is the Sole- Surviving Successor Trustee of The LaCoy Family Trust dated August 19,
1993, and that the foregoing instrument was signed by proper authority, in the capacity and
for the purposes stated in it.
Rqb. oL)(Roln-sr A,)
NOTA UBLIC I` e'
Address: 211 Y}'� Q .{�.Q L' i�,
My Commission Expires:
Notary Public State of Nevada
a County of Clark
k EVELYN W. MADSEN
QQ'', M Appointment Expires
7 June 4, 2011
No: 07-3514-1
Exhibit Legal Description for Lincoln County, Wyoming property
Serial Number W- 0315711
T.20N., R.112W., 6 P.M.
Sec. 30: W% E%, E% W1/2
T.20N., R.113W., 6 P.M.
Sec.26: E%
Containing 640.00 acres, more or less.
000123
COLORADO WYOMING
Moffat County Campbell County
C -14489 W -50361
Montezuma County Converse County
C -11658 70 -2259
C -24974 W- 0317874
W- 0317847 -A
NORTH DAKOTA
Billings County
M- 17500(ND)
UTAH
San Juan County
U -20544
Fremont County
W -9485
Johnson County
W -39577
Lincoln County
W- 0315711
Niobrara County
W- 0317815
Park County
W -39691
Sweetwater County
W -19448
W -22067
W- 023207
W- 024417
W- 025486
W -26207
W- 0318316A
W- 031341
Washakie County
W -41815
W- 46108 -A
W- 0314025
W- 0314025B
Weston County
W -40744
000124
el DECEDENT'S NAME First, Middle. Last)
JAMES F. LaCOY
2 SEX
Male
3 DATE OF DEATH (Month. Day. Year)
February 26, 2001
4a AGE Last Birthday
(Years)
84
4b UNDER 1 YEAR
4c UNDER 1 DAY
5 DATE OF BIRTH (Month Day Year)
July 19, 1916
6 COUNTY OF DEATH
Dickinson
MONTHS j DAYS
HOURS j MINUTES
7a LOCATION OF DEATH (Enter place officially pronounced dead in la, 7b, 7c
HOSPITAL OR OTHER INSTITUTION Name (If not in either. give street and number)
Dickinson Co. Memorial Hospital
7b IF HOSP OR INST Inpatient.
Op lime Room. DOA (Specify)
Inpatient
lc CITY, VILLAGE, OR TOWNSHIP OF DEATH
Iron Mountain
8 SOCIAL. SECURITY NUMBER
9a USUAL OCCUPATION (Give kind of work done dunng most of
working file Do not use retired)
Owned /Operated
9b KIND OF BUSINESS OR INDUSTRY
Oil and Gas Leasing Co.
10a CURRENT RESIDENCE
STATE
Michigan
10b COUNTY
Dickinson
10c LO y- C�ALITY (Check one box and specity)
L=_i INSIDE CITY OR VILLAGE OF
TWP OF Kingsford
10cl STREET AND NUMBER
1811 Woodward Ave.
10e 2(P CODE
49802
11 BIRTHPLACE (City and
State or Foreign Country)
Wausaukee. WI
12 MARITAL STATUS Married.
Never Mashed Widowed.
Divorced (Specify)
Married
13 SURVIVING SPOUSE
(If wire gi a name before first marred)
Mildred Harcourt -Cooze
14 WAS DECEDENT EVER
IN u 5 ARMED FORCES>
(SPeci6 Yes o, No)
No
15 ANCESTRY Me.ii,,n Pu.rto Rican. Cuban. Central or South
American. Chicano. other Hispanic. Afro-American, Arab.
English. French, Finnish, e (Sperry below)
French
16 PACE American md.an Back. Wh4e. etc
h Asian give nationality e Chinese.
F Asian Indian etc (Specify banes!
White
17 DECEDENTS EDUCATION (Sperry only highest grade completed)
Elementary/Secondary (012)
College (1 or 5
2
18 FATHER'S NAME (F rst Middle. Last)
x
14 MOTHER'S NAME (F.,. t 1001dle S0,03.00 Wore r maned.
x_7 ea' a i e Lenerville
20a INFORMANT'S NAME (Type Pont)
1 Witdrod T.aCny
2013 MAILING ADDRESS (Street and Number or Rural Route Number. City or Village. State. ZIP Code,)
P.O. Box 2342 Kingsford. MI 49802
21 METHOD OF DISPOSITION Burial. Cremation,
Removal. Donation. Other .(speedy)
%trial
22a PLACE OF DISPOSITION
i r other +aces
Cemetery Pa
(Name ofCemerery Crematory.
k
225 LOCATION City or Village. State
Iron Mountain. MI
23 SIGNATURE OF FUNERAL SERVICE LICENSEE
l j
J i
24 LICI7JSE -NUMBER
(at L�
6170
<'5 NAME AND ADDRESS OF FACILITY
Erickson- Rochon Nash Funeral Hose
901 Carpenter Ave. Iron Mtn., MI 4901
'RINT
.NENT
INK
1 10198
LF
CF 044
26 PART I Enter the diseases. iniuriei. or mpbr.ations that caused the death Do NOT enter the mode of dying. such as cardiac or respirator,
arrest, shock. or heart ladure 41 only one Cause on each tine
IMMEDIATE CAUSE (F anal ACUTE CEREBROVASCULAR ACCIDENT
disease or condition _i
re in death)
Sequentially 151 conditions
1F ANY teaduig to immediate
ca use nter UNDERLYING
CAUSE (Disease or me,
that in.hated events
resulting .n death) LAST
DUE TO (OR AS A CONSEQUENCE OF
CHRONIC DIFFUSE ARTERIOSCLEROSIS
DUE TO (OR AS A CONSEQUENCt: OF
DUE TO (OR AS A CONSEQUENCE OF)
PART II Other significant conditions contributing to death but not resulting in the underlying cause given in Part f
CHRONIC CONGESTIVE HEART FAILURE
28 ACTUAL PLACE OF DEATH (Home. Nursing 29 WAS CASE REFERRED TO MEDICAL
Home, Hospital. Ambulance) (Sper.dy) EXAMINER? (Specify Yes or No)
Hospital NO
30a To the best of my kno ath c urred a he ime, date and place and due
to the cause(s) steed
Z z (Signature and Title) M D
Et-, 300 DATE SIGNED (Mo 1.. Yr) e 1 TIME OF DEATH
Q.
FEBRUARY 27, 2001 5:30 am
30d NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER 7
YPe or Runt)
33e' INJURY AT WORK
(Specify Yes or No) office building. etc (Specify)
a; i 0 RAR'$.SIGNATU
r, tee
INJURY At home, farm. street, factory.
STATE OF MICHIGAN
DEPARTMENT'OF COMMUNITY HEALTH
CERTIFICATE OF DEATH
33a ACC :SUICIDE: 'HOM ,'NATURAL
0R PENDING INVEST (Specify)
320:: LICENSE' NUMBER
4 3493
32a. NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH (ITEM 26) (Type or Punt)
331 PLACE OF
33c. TIME OF
PRONOUNCED DEAD (Mo Day. Yr
ON
33d .DESCRIBE HOW INJURY OCCURRED
31c CASE NUMBER
31e TIME OF DEATH
31a The case reviewed and determined not to be a medical examiner's case
(Check a
one On the basis of examination and of Investigation. in my opinion death occurred
only) at the time, date and place and due to the cause(s) and manner stated.
INJURY
M
31b
31d
0000 00787
27a WAS AN AUTOPSY
PERFORMED?
(Yes or No)
NO
Yr
340. DATE FILED, (Month, Day. Year)
February 26 2001
STATE FILE NUMBER
1680179
Apuroiimate
1 Interval Between
Onset
and
5 DAYS
'n
I YEARS
270 WERE AUTOPSY FINDINGS
AVAILABLE PRIOR TO
COMPLETION OF CAUSE
OF DEATH' (Yes Or No)
N0
33g LOCATION Street or R F 0 No City. Village or Twp State
I. DECEDENT'S NAME. ,Pura 111d11, 1.r..',
MILDRED H. LaCOY
2. DATE OF 131R1'l1 rll.mh (110. Ilk',
FEBRUARY 23, 1913
3. SEX
FEMALE
1 1
4. DATE OF DEATH (Month. Dar. Yoe,
JULY 19,2009
5. NAME. AT 11112111 OR (/H11'l1 NAME t'SI•D F PERSONA' IR'SINESS n,,lnd. AK a. n,.1,„
MILDRED H. HARCOURT -000ZE
6a. AGE last Birthday
"r"
96
611. UNDER I Y :AR
6c. UNDER DAY
MONTI'S I DAYS
j
HOURS
MINUTES
70. 1.0('ATION OI. 1)I:ATII rEno'r place of/kin/b.....atone& Arad of '1,. 'h
HO.SI'ITAL OR 0111ER INS I l I' )'ION Namc nl not 0■ ,min,. am .,n,1, „,,.l 0111014rr ...h-,
DICKINSON COUNTY MEMORIAL HOSPITAL
7b. CFI Y. VILLAGE. OR TOWNSHIP OE DEATH
IRON MOUNTAIN
7c. COUNTY OF DEATH
DICKINSON
110. C1 '1412BN1' RESIN. NIA
STATE
MICHIGAN
411. ('(1UN 0'
DICKINSON
Xc.,-.i /.i 11 Y win. A d„ n„. Mar d,., rn, h.,1, o,
]AL 1,111 ,rn\vw 0,, 141 +nl,uu
s a s KINGSFORD
&I. 5')51411' ANI) N(IMIH4K hmh.dr• Apt .ve it applicable,
1811 WOODWARD AVE.
110. /11' CODE
49802
'4. 1115'1111'1 Al I- a 'al .oil vow ,r
CALGARY,ALBERTA,CANADA
1 11. S( ICI AI. SI 1 rlY' NI IMREtt
11. DECEDENT'S F What Is to highest
dr4100 or lour of suhmd completed nl the time of dcalb?
FOUR YEARS COLLEGE
12. RACE Amcnca, Inman whm•. Rlucl. er n( 1.on, go,. n „men "hr,
6 Chun., 1711,.,,.,. flu,, r lu,hrn, eh r Woa'r all deco ,q r
WHITE
13a ANC! ti 1 1 1 5' M,•,,,an. 1010,.,. \ml.. Ahwm. I ncll.I,. lon,h, Dutch. ele
.1 nn, all non upp4. D •vom hullo! n. ,•um, 4010014a) mho•
ENGLISH SCOTTISH BURMESE
1311. HISPANIC ORIGIN
.1e. 1,r .\'o1,
NO
14. WAS UCl'1iDaNT EVER IN
THE U.S. ARMED FORCES?
D ns ,m un)
NO
(5. USUAL OCCUPATION (no Arm/ A nark dam,
during moat al ,row *mg I, /r U. o. 1111' 1111' 10111
SALESPERSON
16 K INI) I/1131'SINESS OR INDI"S'l 11 Y
OIL COMPANY
J 7. MARI 1111. X14 f1 Mimi.
,,er %mat. Winonrd. Ih,creed
e.cp,. ern
WIDOWED
In NAME OE St1RVIVIN(i SPOt :SP. 0 /0 /e. gbr Dame NO.'
l,r,l marred,
17. FATHER'S NAME doll. ANAOe. 1.0014
GORDON S. HARCOURT -000ZE
211 MO1111 II'S NAMI. HEF(IR14 111451 MARRIED (to,,, AIWA, I.au,
ELIZABETH •MAXWELL
21a. INFORMANT'S NAME. iliyn•l'rmu
LORRAINE LaCOY
21 b."111.1 ATWN51111' II
OIL Ii1)1.N'1
SISTER- IN-LMI
21e M AILING 41)1)51. 5S l571.1e1 and %umbel or 11ur.1 Hole .Yaulh ('1,0 nr li4,g,'. .5'(wr•. /I/ 1
918 EAST C STREET IRON MOUNTAIN, MI 49801
22. 411:1'1101) DE DISPOSI'1'IIIN
I5ri111, Cremation. Ilntun,hmc,n.
I)unnlnn. Renm,nd Storage L(perrh,
CREMATION
23a. PI A('P Il1 DISPUSIII( „/a ccrue.) .>eoamr All ono'',
WILBERT CREMATORY
231,. LOCATION City or Village. Slate
ESCANABA. MICHIGAN
24. SIGNATURE OE MOIt'1'U 54 (1NC'p. LICENSE/.
2St'l 1('EN51•.NI'MHI•R
4151 l ,r,•,nr,•;
5618
26. NAMI. AND AUURE.SS OP FUNE.RAI. FAcil.l'ry
2 ERICKSON- flOCHON NASH FUNERAL HOME
901 CARPENTER AVE. IRON MOUNTAIN, MI 49801
27n. CERTIFIER l( 'heck mdr ,,m,
Ti
•M <'erlifyinµ 1'hysiclnn Tn the hest nl my A halo. ,61111
1-7 Mecal 111, nu tl, hlsl. of ennmnm,. and,
L 1 100,0,411 m We r,n1a•. dnln. al' pl• I due m to th 1
re-
Signature and Title
mato d ilia In Ibe nna, ,rid:
n m,e•.l:11::t a 1puwou. &oh. r
nr Dud r�
2111,. A(' 11(41. 05I'Ill,SIIMED
1'IML' O P1)EAl'II
A
21/h. 1'51)141)l1N('l /D I)1'.AI) ON
1 Alo Um 1r,
JULY 19, 2009
25.. 'rIMR PRONOUNCED
DEAD
4:15 A M
2'). 411.1)1(4 I EXAM IN ER
TA( .11.1) r rl'r n, 401
NO
314 I LA('I. Oi 1)1441'11 1110100. 11.0111.'..
Mom It Rune. Il.sprhd. Ambulance 1 ape( /11
HOSPITAL
31 IF I10,PITAL. blpntienl„161pmnca4
Emergency )loom: DOA iSpe pp)
INPATIENT
271). 1)41 51GNI(1) .Ma Oar )'r, 1 27..1 ICI "(SI. NI .1)4111 it
7 2o Oct' 33052
12 MLDICAI. 1 XAMIN1'5
"1! 4141 IN 01
33. NAMI: OF ATTENDING l'IIYSI('IAN IF 0'1'111111 T11AN
(1'.I1'I1P11'It 1 /1p,w'Vaal,
'PRINT
N
ANENT
K INK
'EDEN T
,RENTS
(MANT
3ITION
'AVON
CAL
IINER
4113 I /1,113
LF
CF
187
34. NAME. AND ADDRESS 01' (,IiI1'rIFYIN(i PHYSICIAN „r rn,nr
39. MANNI(R OF DF:ATII Accident. Suicide. llnnncid
Natural. Indeterminate or Pending 'Spode,
NATURAL
r 41a. DATE. OF INJURY
1111, 11,0 1'r,
41d. INJURY AI W(II(K
410 PLACE 1 E 15)4'1(5 AI home,
)arm. ctr CL construction situ.
„uodcd 1 ran. etc ,.1) dr
r( 1
STEPHEN LEONARD, M.D. 1711 S. STEPHENSON AVE. IRON MOUNTAIN, MI 49801
!STRAWS SICNAI 141RF A 151, DA EE HEED (.)bnuh. tar lean
,4
July 21. 2009
PART 1. linter the tin of events diseases. injuries, or wlifphc11 1 1 1001 u the death DO NO 1', :n1cr lenmmnl events such as cnrdmc arrest, respiratory arrest I Approsinxue
ittervnl Between
or ventricular fibrillation without Showing the etiology lemur only one:caItSe I a h Onxt ant Death
If diabetes was tin Immediate.
inl: C y i e �R _y`�[/�/.',•(/�,
cause of death he cure hr
underlying or contrib. 11 1 201Z
record dmhntvs m either fart 1 DIT ID I I I AS A 10hIS11,1 M 1 1411
TR
Of l'1111 11 of t come of V
SE OF death sa t 1 t as upp,pnmc 40 t k y n 20
IMMP;111Ai'h. ('41151 (Fu11 DI 3 1 1n AS A 1't1NSI'QI'1 NI'1 1111
disease or conduit,.
I
Sequentially lot condoions.
IF ANY. luading lo the Louse
listed an line a. Enter Ilia
UNDERLYING CAUSE
initiated the etenis resulting
I
in death) LAST
DUI ID t110 35.5 1 t WShgl.'1 NCI 01
4111. 1IMF. Uh INJ('RY
51
40a. WAS AN At''lOI'SY
1'1..51 117(1111)"
5,.,
NO
STATE OF MICHIGAN
DEPARTMENT OF COMMUNITY HEALTH
CERTIFICATE OF DEATH
PAI(T II. 0))11g3 Su;N)hR .AEI ('115(11'111,55 cunlnhultng to dea but nil revelling in the underlying cause gsen In I',ri I.
41c. DES('I(IHI, 1111W 15)1(13Y OCCURRED
4 1 1 I t 'IRANSP111(
INJURY Drier I/Know.
l'a..engel. 1'Mc etc. I Sprr at
37. 1)11) 11HA ('(3) US I?
('ON'F111 litI'I'I:'((1 I)EA'Fi 1?
Pr.ahl,
■o j 1 1,1110„ n
411,. 6'(112/. Art( R'SY FINDINGS AVAII.AI!I.E
TRIO)( r1) ('OMPIETION OF CAUSE 111
DI .I'll'' 1,e. Uo
41g. It )4 A Ell /5 Street or RED No.
00425'65 000126
STATE FILE NUMBER
36.11 I'I'MAI.7.
Nat pregnant within puss )car
[1 Pregnant nI none of death
I..I 5 1 4 E 1 I. 11 t p 4- ant It J_ illy. f d Ih
L J Not pregnant, hat pregnant 43 days 0, I year
f before death
1. 1 1'04 ,,4 d prgnann wntu, the pass year
City, Village or 1115,., State
CERTIFICATIO ITAL RECORD
ft"
Decedent:
Name;: James Randall LaCoy
Gender: Male
Date of Birth: July 05, 1949
Date and Place of Death:
Date of Death: May 31, 2006:
City of Death: Cheyenne
Additional Decedent Information
Place of Birth: Cheyenne, Wyoming`
Residence: Cheyenne, Wyoming
Marital Status: Divorced
Name of Father: James Francis LaCoy
Maiden Name. of Mother: Eva June Hein
Informant: Gay Lee Guckenburg
Certifier:
Name:
Address:
This is a true certification of the document on file in the office of Vital
Records Services, Cheyenne, Wyoming.;
June:28, 2006
This copy is not valid unless prepared on paper with an engravi d!boder.
DEPARTMENT OF HEALTH
DEATH CERTIFICATE
State File Number: 2006 001773
Social Security Number:
Age at the Time of Death: 56 years
Manner of Death: Accident Time of Death:
William C Ryan, Coroner
310 W 19th St, Cheyenne, Wyoming
County oof< Death: Lararnie
Relationship: Sister
Disposition:
Method of Disposition: Cremation
Place of Disposition: Sunset Perk Crematory, Cheyenne, Wyoming
Cause of heath:
The immediate cause is listed on the first line followed by any underlying causes.
(a) Pneumonia
(b) Numerous Rib Fractures
Other Significant Conditions: Ateleotasis Lt. Lung, Severe Alcohol Abuse
Injury Information:
Date of Injury: Time of Injury
Location: Unknown, Wyoming
Description of How Injury Occurred: Fell, possibly numerous times, fracturing his ribs
Brent D. Sherard, M.D.,'M.P.H.
Director and State Health Officer
a A
r �.r�.�ira., m9ii ,le3is ,:a��
9
RESIGNATION AND
DESIGNATION OF TRUSTEE
Lorraine A. LaCoy is the acting Trustee of the The LaCoy Family Trust Dated August
19, 1993, FIN 021 -03 -7873. Under authority of Article 1.3 of the trust, Lorraine A. LaCoy
resigns, effective the date of this document, as Trustee of the LaCoy Family Trust Dated August
19, 1993.
Dated this 27 day of August, 2009.
WITNESSES:
STATE OF MICHIGAN
COUNTY OF DICKINSON
Personally came before me this 27th day of August, 2009, the above named Lorraine A. LaCoy,
Trustee, to me known to be the person who executed the foregoing instrument and acknowledge
the same.
Prepared by: Suzanne M. Fleury P47895
Attorney at Law
P.O. Box 743
Iron Mountain, MI 49801
mss/
orraine A. LaCoy, Trustee G�
s Mulder
SS:
Su M. Fleury, Notary Public
Dickinson County, Michigan
My Commission expires 04/27/11.
000128
ACCEPTANCE OF TRUST
Gay Lee Guckenburg is named as a successor trustee of The LaCoy Family Trust Dated
August 19, 1993, EIN 021 -03 -7873, after the resignation of Lorraine A. LaCoy, first successor
trustee Gay Lee Guckenburg signs this acceptance and agrees to serve as trustee immediately
upon signing this document and agrees to be bound by the terms, conditions, and responsibilities
of an acting trustee under the trust agreement.
Dated this day of ;�Lt ?�C5 T 2009.
WITNESS:
STATE OF u.T=-{ t
COUNTY OF `>F i
Personally came before me this 3 day of uci tas r 2009, the above
named Gay Lee Guckenburg, to me known to be the person who executed the foregoing
instrument and acknowledge the same.
i_UANN■ H. GREENWELL
Notary Public
State of Utah
My Commission Expires Feb. 27. 2011
106 'West Mn, ali Meer; Pfeasant., UT 84647
Prepared by:
Suzanne M. Fleury P47895
Attorney at Law
P.O. Box 743
Iron Mountain, MI 49801
2
SS:
000129
Z, tU/Z
Gay Lee uckenburg
t Notary Public
Acting in the County of a,r, p k --e
County, State of U
My Commission expires: 4_Lb Xl L L i i