HomeMy WebLinkAbout960625For:
(Deceased)
Legal Description: See Exhibit "A" attached hereto and
made a part hereof.
Well Number Name:
County, State:
!ILl, e_ Vl1Rlt�
(Name of Affiant)
(City)
JEANNINE PONT
1. How long and how well were you
acquainted with the decedent?
2. If related to decedent, state in what way.
3. When and where did decedent die?
5. How many times was decedent married?
6. Name and address of surviving spouse (if any).
residing at
AFFIDAVIT OF HEIRSHIP
residing at
4. Where was decedent's permanent residence at the time of his /her death?
Wasa 1
(Address)
4 .-61- being first duly sworn, on oath deposes and
(State) says that the answers and other statements
hereinafter set out are true and correct.
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RECEIVED 8/19/2011 at 10:32 AM
RECEIVING 960625
BOOK: 771 PAGE: 405
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
000405
XTO ENERGY INC. OWNER #:36724
7.19.2011
30% 35 -11- S4 014.. UT MI
Date of
Marriage
4
Name of Spouse
Name of Child's Other
Parent
Birth
Date
Marriage
Terminated
by Death or
Divorce
Date of
Termination
Address if Living
Living or
Dead
If dead, did
such spouse
leave a Will
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Name of Child
Name of Child's Other
Parent
Birth
Date
Address
Living or
Dead
If Dead, Give
Date of Death
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7. If decedent was ever married, list in the following table each such marriage, indicating in each instance the date of marriage, the
name of spouse, whether such marriage was terminated by death or divorce, the date of termination of the marriage, the address of
each spouse now living, and (if dead) whether or not such spouse left a will:
8. (a) When was the property described at the beginning of the affidavit acquired by dece
(b) Was it acquired by gift, devise, inheritance or purchase? (State which) )A
(c) If by purchase give the following information:
(1) Where did decedent reside (the State in which decedent had his /her permanent
when property was acquired?
(2) Was the decedent married when such property was acquired?
If so, give the name of decedent's husband or wife.
If such husband or wife is now deceased, did such party leave a Will?
9. Did Decedent leave a Will? WI
A/!4-
(a) If yes, was the Will probated?
(b) If the will has not been probated, does the executor or administrator intend to probate the will?
10. If decedent did not leave a Will, was any administration had on decedent's estate?
If so, name the counties and states in which administration was had and give the name and address of the
administrator.
11. To your knowledge are there any debts or Federal estate or state inheritance taxes still owing by
decedent's estate?
If so, will decedent's personal estate be sufficient, in your opinion, to pay such debts and taxes?
What is the estimated net value of the entire estate?
ent? 199g
residence will suffice)
12. List in the following table the name of all children born to or adopted by decedent, whether living or dead,
giving all other information called for in the table below. Any adopted children should be designated as
such if decedent had no children, so state.
2
600406
*If the will was admitted to
probate, please provide copies
of all probate documents.
ttlo
i joz), c)eo
Name of Deceased Child
Descendants
Birth
Date
Address
Living or
Dead
If Dead, Give
Date of Death
fin,
/b
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Name of Deceased
Brother or Sister
Descendants
Address
Age
Living
or Dead
If Dead,
Give Date
of Death
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
Name of Deceased
Brother or Sister
Descendants
Address
Age
Living
or Dead
If Dead,
Give Date
of Death
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
13. Give information called for in the following table concerning descendants of any deceased child of decedent
(whether natural or adopted). If no descendants, so state.
Descendants of deceased child of decedent. If none, so state.
14. If decedent left no surviving child or descendant of a child, then list names of decedent's parents and brothers
and sisters and give information called for in the following tables. If half brother or sisters, state whether
maternal or parental.
Name Address
Father
Mother
Brother
Brother
Sister
Sister
Descendants of deceased brothers and sister. If none, so state.
15. If decedent left no children or their descendants, or father or mother, or brothers or sisters or their
descendants, then give the information called for in the following tables:
3
003407
Living or If Dead, Give
Dead Date of Death
Name
Address
Living
or
Dead
If Dead,
Give
Date of
Death
Paternal Grandfather
Paternal Grandmother
Maternal Grandfather
Maternal Grandmother
13. Give information called for in the following table concerning descendants of any deceased child of decedent
(whether natural or adopted). If no descendants, so state.
Descendants of deceased child of decedent. If none, so state.
14. If decedent left no surviving child or descendant of a child, then list names of decedent's parents and brothers
and sisters and give information called for in the following tables. If half brother or sisters, state whether
maternal or parental.
Name Address
Father
Mother
Brother
Brother
Sister
Sister
Descendants of deceased brothers and sister. If none, so state.
15. If decedent left no children or their descendants, or father or mother, or brothers or sisters or their
descendants, then give the information called for in the following tables:
3
003407
Living or If Dead, Give
Dead Date of Death
Name
Uncle or
Aunt
Age
Paternal or
Maternal
Address
Living
or
Dead
If Dead Give
Date of Death
Name of Deceased Uncle
or Aunt
Descendants
Age
Address
Living
or
Dead
If Dead
Give Date
of Death
THE STATE OF ULNA—.
COUNTY OF \1)-(_,1/4)41-1‹._
Signature of ffian
The foregoing instrument was ,subscribed and sworn before me on this the
by� l 1
lG(. F 1./L /Z>/Gf
4
�W day of
1 040 8
Notary Public, State of
My Commission Expires: WV/j.-0/5
Printed Name of Notary: ,Em f3/Ay 4/1/4-71—i
ELAINE BINGHAM
T
NOTARY PUBLIC PATE ofUTAH
I COMMISSION NO 610983
i u
1 COMM. EXP. 06/21 /2015
FONT FED 21 -08 XTO WELL 65247
SECTION 8 T25N R112W
LINCOLN,
EXHIBIT "A"
000409
*The well description(s) shown on this Exhibit "A" cover this owner's mineral and /or royalty interest according to the
records of XTO Energy, Inc. It is not intended to represent this owner's entire mineral and /or royalty estate.
5