HomeMy WebLinkAbout957935AFFIDAVIT FOR DISTRIBUTION OF ASSETS
IN LIEU OF PROBATE
The State of Wyoming
ss.
County of Sweetwater
000850
Janet L.H. Smallwood, of lawful age, after first
being duly sworn upon her oath according to law, deposes
and says:
1. This Affidavit is made pursuant to the
provisions contained in Section 2 -1 -201, Wyoming Statutes.
2. Ray C. Smallwood, also known as Ray Craig
Smallwood, died on the 23rd day of December, 2010, in Salt
Lake County, Utah, as evidenced by the certified copy of
the Certificate of Death, which is attached hereto, marked
Exhibit "A and by this reference made a part hereof.
3. Affiant, Janet L.H. Smallwood, is the
surviving spouse of the decedent, Ray C. Smallwood.
4. Ray C. Smallwood was a resident of Sweetwater
County, Wyoming at the time of his demise.
5. The value of the entire estate of Ray C.
Smallwood, wherever located, less liens and encumbrances,
does not exceed $150,000.00.
6. As shown by the Death Certificate attached
hereto, more than 30 days have elapsed since the date of
death of decedent, Ray C. Smallwood.
7. No application for the appointment of a
Personal Representative or probate of decedent's estate is
pending or has been granted in any jurisdiction.
8. Ray C. Smallwood left surviving him as his
surviving spouse the following, who is entitled to
distribution of the entire distributable assets of his
estate:
Janet L.H. Smallwood, surviving spouse, of legal
age, whose mailing address is 1230 South Dakota,
Green River, WY 82935
9. The only assets of the estate of the
decedent, wherever situate, as known and discovered by
Affiant, with the probable value being shown, are as
follows, to wit:
One (1) 2001 Buick 4DR, VIN 1G4HP54K11U293050,
covered by Wyoming Certificate of Title No. 12-
RECEIVED 2/4 /2011 at 9:44 AM
RECEIVING 957935
BOOK: 761 PAGE: 850
JEANNE WAGNER
1 IM('C 1 M rem IAITV r1 CAL! LVC11ARACDCD \AIV
0251230, standing in the name of Smallwood, Ray
C., the total probable value of which is no
greater than $2,450.00; and
Bank of the West Savings Account Number 005833780
in the name of Ray C. Smallwood, the total value
of which is no greater than $800.00.
10. The Affiant, Janet L.H. Smallwood, as
surviving spouse of the decedent, pursuant to probate
proceedings in the State of Wyoming, would be entitled to
have the entire estate of not less than $30,000.00
distributed to her pursuant to Sections 2 -7 -504 through 2-
7 -508, inclusive, Wyoming Statutes. The said Janet L.H.
Smallwood hereby selects and designates the aforesaid
property as homestead exempt property which she is entitled
to receive. Therefore, there are no other heirs at law or
distributees of the decedent having a right to the above
described property under probate proceedings or otherwise.
There are no other persons who have a right to succeed to
the above described property under any probate or other
proceeding. Pursuant to probate proceedings in the State
of Wyoming, Janet L.H. Smallwood would be entitled to have
the entire estate of the decedent distributed to her.
11. In accordance with the foregoing matters,
the Affiant is requesting that the decedent's interest and
the ownership and certificate of the Title to the property
described above be set over and distributed to her as her
separate property, as provided by the laws of the State of
Wyoming, particularly Sections 2 -7 -504 through 2 -7 -508,
inclusive, and Section 2 -1 -201, of the Wyoming Statutes, as
noted hereinabove.
Dated this
The State of Wyoming)
ss.
County of Sweetwater)
My Commission Expires:
2
day of 2011.
Janet L.H. Smallwood
Signed and sworn to before me
:-J2,1TV-ta. I W_
2011 by Janet L.H. Smallwood
&jai( i) N2,
Notary Public
T AAA- o
004A51
on
CERTIFICATI
ITAL RECORD
V11 !1",V I.. r. �v'l51Y v r v......iYY r }51 }VVJF /V151 rJr }frl.J(.r }x.551.• ••r fV '!5'!11'r'!Y'r}'J }1.
.A'. \A.. 5.. _1Af4\.l 1,J/AWOOA_t_ANA AA.�\A.tf t A__1tAt14.1.... _WtV..!J'&"W......MA /tr 4- t ht H�
v •I f
4S4 0
DECEDENT INFORMATION
Date of Death:
City of Death:
Age:
Place of Birth:
Armed Services:
Spouse's Name:
Industry/Business:
Residence:
Mother's Name:
Facility or Address:
INFORMANT INFORMATION
Name: Janet Lee Smallwood
Mailing Address: 1230 South Dakota Street, Green River. Wyoming 82935
DISPOSITION INFORMATION
Method of Disposition:' Cremation
Place of Disposition: Independent Professional Services, Taylorsville,
Date of Disposition: December 28, 2010.
FUNERAL HOME INFORMATION
Funeral Home: SereniCare Funeral Home, 1_1_6
Address: 12278 South Lone Peak Parkway, Suite #103, Draper, Utah
Funeral Director: Terry Eckersell
MEDICAL CERTIFICATION
Certifying Physician: Sean D Overton M D, 50 North Medical Drive, Salt Lake, City (Salt Lake), Utah 84132
CAUSE OF DEATH
Hyperkalemia
Due to (or as a consequence of): Renal Failure
Due to (or as a consequence of): MVA Traumatic ,Injury
Due to (or as a consequence of): Pulmonary Hypertension
Tobacco Use: Unknown if User
Medical Examiner Contacted: Yes Autopsy Performed: No Manner of Death: Accident
INJURY INFORMATION
Date of Injury:
Injury at Work:
Location of Injury:
How Injury Occurred:
Motor Vehicle Accident:
Date Issued: January 6, 2011
AMENDMENT HISTORY
01/06/2011 Decedent Date of Birth from 08/25/1950 to 08/28/19
December 23, 2010
Salt Lake City
60
Caldwell, Idaho
Yes
Janet Lee Hackman
Industrial
Green River, Wyoming
Theda Laverne Morrison
University of Utah Hospital
�`y vvM D1w11111111 VIII I*
CERTIFICATE OF DEATH
State File Number: 2010014802
!Ray Craig Smallwood
Time of Death:
County of Death::
Date of Birth:
Sex:
Marital Status:
Usual Occupation:
Education:
Father's Name:
Facility Type:
Relationship: Wife
December 13, 2010 Time of Injury: 07:00
Yes Place of Injury: Highway
Hwy 30, approx 15 miles. East of Opal, Wyoming, Rural, Wyoming.
Vehicle rolled over and deceased was ejected.
Driver
17 :45
Salt Lake
August 28, 1950
Male
Married
Electrician
Some College but No Degree
Lester Hershel Smallwood'
Hospital inpatient
Exhibit "A"
Utah
84020
i III uu 1111111 i
m
This is an exact reproduction of the document registered in the State Office. of Vital Statistics.
Security features of this official document include: Intaglio Border, V R images in top cycloids,
ultra violet fibers and hololaram, image of the. Utah State Seal, over the words "State of Utah
This document displays the date, seal and signature of the State Registrar of Vital Statistics.
UTAH DEPARTMENT OF HEALTH
Office of Vital Records Statistics
Salt Lake City, Utah
00C/852