HomeMy WebLinkAbout957480STATE OF WYOMING
AFFIDAVIT FOR DISTRIBUTION 00 i*O9.S
OF DECEDENT'S PERSONAL PROPERTY
PURSUANT TO W.S. 2 -1 -201
ss.
COUNTY OF LINCOLN
I, SCOTT EDWIN HYDE, being first duly sworn, on oath depose and
state that I am making this Affidavit pursuant to W.S. 2 -1 -201, on behalf
of myself, as distributee, as hereinafter set forth, that I make the following
statements in connection therewith:
1. That DORIS JUNE HYDE became deceased on October 30,
2010 in Afton, Lincoln County, State of Wyoming, and was a resident of
Afton, Lincoln County, State of Wyoming, at the time of her death; that said
decedent died intestate; that said decedent left Scott Edwin Hyde, Mark
LaMoyne Hyde, and Terry Keith Hyde, as surviving children; that the sole
and only parties entitled to the estate of said decedent are the distributees
hereinafter named; a copy of the Certificate of Death of decedent is attached
hereto as Exhibit "A
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. That the following named distributees are the sole and only
parties 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 distributees are entitled to payment or delivery of all of the
decedent's property:
7. That an executed copy of this Affidavit is being presented to the
transfer agent for the above listed asset in compliance with W.S. 2 -1 -201.
Furthermore, pursuant to W.S. 2 -1 -201, the depository for any income or
Affidavit for Distribution
Page 1 of 2
RECEIVED 1/5/2011 at 9:57 AM
RECEIVING 957480
BOOK: 760 PAGE: 18
JEANNE WAGNER
Name
Scott Edwin Hyde
Mark LaMoyne Hyde
Terry Keith Hyde
Relationship
Son
Son
Son
6 That among the assets owned by said decedent is the following:
a. 1998 Dodge pickup VIN 3B7HF13Z6WG205375
b. Home and real property located in Afton, Wyoming
000019
interest in the above entitled asset is hereby directed to pay any deposit or
any funds in said account that were in the name of the decedent, together
with any interest and dividends thereon, payable to distributee listed here.
Name and Address Date of Birth Social Security No.
Scott Edwin Hyde 09/13/65
200 Heap Dr.
P.O. Box 441
Thayne, WY 83127
Mark LaMoyne Hyde 02/22/73
194 Hialeah
P.O. Box 794
Afton, WY 83110
Terry Keith Hyde
1179 North 780 West
Clinton, UT 84015
EXECUTED this ,,21
STATE OF WYOMING
ss.
COUNTY OF LINCOLN
SUBSCRIBED AND SWORN to before me by SCOTT EDWIN
HYDE this ..J 5r day of December, 2010.
CRYSTAL L. SLAL'GHTER NOTARY PUBLI
County of
Lincoln
State of
Wyoming
My Commission 'ilxpir4; tybruery 3, 2014
My Commission Expires: /7).
09/13/65
day of December, 2010.
SCOTT EDWIN HY _)E
SSN:
Address: 200 Heap Dr., P.O. Box 441
Thayne, WY 83127
NOTARY PUBLIC /PUBL PUBLIC i 9C
Affidavit for Distribution
Page 2 of 2
This is a true certification of the document on file in the office of Vital
STATE OF WYQMING
DEPARTM OF ;HEALTH'`
Decedent: State File Number: 2010 003517
Name: Doris June Hyde
Gender Female Social Security Number
Date of Birth: October 13, 1942 Age at the Time of Death: 68 years
Date of Death: October30, 2010 County of Death:
City of Death: Afton
Location: Star Valley Medical Center 110 Hospital Lane
Additional Decedent Information:
Place of Birth: Jackson, Wyoming
Residence: Afton, Wyoming
Marital Status: Widowed
Armed Forces: No
Name of Father James Edwin VanVieet
Name of Mother: Wanda June Jump
Informant: Scott Hyde Relationship: Son
Disposition:
Method of Disposition Burial
Place of Disposition: Smoot Cemetery, Smoot, Wyoming
Funeral Home or Facility:
Facility: Schwab Mortuary, Afton, Wyoming
Cause of Death:
The immediate cause is listed on the first line followed by any underlying causes Interval:
(a) Sepsis
(b) Pneumonia
(c) Neutropenia
(d) Myelodysplastic Syndrome
Other Significant
Conditions:
Manner of Death: Natural Death Time of Death: 06:35 (Actual)
Certifier:
Type: Physician
Name: Michael R. Pieper, D.O.
Address: 110 Hospital Lane, .PO Box 579, Afton Wyoming, 83110
Date Filed: November 16, 2010
Statistics Services, Cheyenne, Wyoming
DATE ISSUED: Thursday, Dedemper>09, 2010
f This copy is not .valid unless prepared on paper with .an engrauedborder-
Gladys K. Breeden
Deputy State Registrar
Lincoln
alry dttk d' f i:�
CERTIFICATIO ITAL RECORD