HomeMy WebLinkAbout960978AFFIDAVIT FOR DISTRIBUTION
OF DECEDENT'S PERSONAL PROPERTY
PURSUANT TO W.S. 2 -1 -201
RECEIVED 9/14/2011 at 9:59 AM
STATE OF WYOMING RECEIVING 960978
SS. BOOK: 772 PAGE: 735
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
I, JACK ELWIN MOORE, 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, 0 0 7 3 5
distributee, as hereinafter set forth, that I make the following statements in
connection therewith:
COUNTY OF LINCOLN
1. That JOAN MOORE became deceased on May 27, 2003 in Cameron,
Milam County, State of Texas, and was a resident of Cameron, Milam County,
State of Texas, at the time of her death; that said decedent died intestate; that said
decedent left Jack Elwin Moore, as surviving spouse; that the sole and only party
entitled to the estate of said decedent are the distributee 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 distributee is the sole and only party
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 distributee
is entitled to payment or delivery of all of the decedent's property:
Name Relationship
Jack Elwin Moore Husband
6. That among the assets owned by said decedent is the following:
ITEM LOCATION APPROX. VALUE
Mineral rights /royalties EOG Resources, Inc. $1,565.64 /net per year
OWNER NO. 080527 (dependent upon production)
Attached hereto as "Exhibit B" is Joan Ryan Moore's Ownership Interest in EOG
Resources, Inc. Inherited by Jack Elwin Moore (Owner No. 080527), which details my mineral
rights and royalties in EOG Resources, Inc., i.e, property numbers, deck numbers to the wells,
and the amount of ownership interest to the same. The net value that I receive each year from
EOG Resources, Inc. is dependent upon each well or deck's production for that year and it can
vary from year to year.
AFFIDAVIT FOR DISTRIBUTION
OF DECEDENT'S PERSONAL PROPERTY
PURSUANT TO W.S. 2 -1 -201
Page 1 of 2
7. That an executed copy of this Affidavit is being presented to the 0 0 0 7 3 6
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 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 herein.
EXECUTED this 4 day of r.0t5 2011.
JACK ELWIN MOORE
Address: 2739 Creekfront Drive
Green Cove Springs, FL 32043
NOTARIAL OFFICER
STATE OF Mr r e.
ss.
COUNTY OF el
SUBSCRIBED AND SWORN t before me, a Notarial Officer, by JACK
ELWIN MOORE this No day of t other 4 2011.
My Commission Expires: 032lc J /lk7i J
TARIAL OFFICER
AFFIDAVIT FOR DISTRIBUTION
OF DECEDENT'S PERSONAL PROPERTY
PURSUANT TO W.S. 2 -1 -201
Page 2 of 2
CERTIFICATION OF VITAL RECORD ff
i::Jj4,
STATE OF TEXAS
1. NAME OF DECEASED; (a) FIRST. (b) MIDDLE (c) LAST ,1d) MAIDEN 2. SEX 3. DATE OF DEATH
JOAN MOORS i RYAN FEMALE 5-27-2003
4. DATE OF BIRTH 5. AGE IF UNDER 1 YR. IF UNDER 1 DAY 6. BIRTH PLACE (CI1Ya STATE OR FOREIGN COUNTRY) 7. SOCIAL SECURITY NO.
pNY ARS) MO DAYS HOURS MIN
9-10 -1938 6+ Los ANGEL C ALIFORNIA
B. RACE W. W THE DE 9b. IF VES. SPECIFY (MEXICAN. CUBAN. PUERTO 10 WAS DECEDENT EVER IN 11. EDUCATION (SPECIFY HIGHEST GRADE
OF HISPANIC O1il 1 RICAN. ETC? U.S. ARMED FORCE COMPLETED. ELEM. OR SECONDARY
CAUCASIAN YES NO YE5J. NO (P12) CO LEGS (13.16. 174) 14
12. ITAL STATUS 13. SURVIVING SPOUSE (IF NFL GIVE MAIOEH:HAME) I10 DECEDENTS USUAL OCCUPATION 11b. KIND OF BUSINESS OR INDUSTRY
MARRIED 8 NEVER MARRIED
WIDOWED DIVORCED JACK MOORS ADMINISTRATIVE ASST. HOSPITAL:
15.. RESIDENCE STREET ADDRESS 150. CITY OR TOWN
1057 CR 139 CAMERON
156. COUNTY 154. STATE I5.. 21P CODE 151. INSIDE CITY LIMITS
MILAN TEXAS 76520 YES C I NO
16. FATHER'S NAME -'47. MOTHER'S .MAIDEN NNAE
THOMAS EUGENE RYAN ELIZABETH YOUNG
18. PLACE OF DEATH (CHECK ONLY ONE)
HOSPITAL INPATIENT EPJOUTPATIENT DOA 1 OTHER: NURSING HOME RESIDENCE OTHER (SPECIFY)
19. COUNTY OF DEATH 20. CITY OR CIT
TOWN OF OUTSIDE WY LIMITS. GIVE PRECINCT NO.) R
21. NAME OF HOSPITAL OR INSTITUTION (II 1101 In institution, show 61,0.1 address)
MILAN PRECINCT 112 1057 'CR 139
22. INFORMANT SIGNATURE&. RELATIONSHIP 23. MAILING ADDRESS OF NFORMANT
JACK MOORS HUSBAND P.0. BOX 936, CAMERON, TEXAS 76520
24. METHOD OF DISPOSITION 25.. PLORYOR ACE OF OI DIHESR POSITI PLACE( ON NAME OF CEMETERY. 258.
5.6140. 29. NAME ADDRESS OF FUNERAL HOME
CREMAT
WALKERS CREEK CEMETERY Block MAREK- BURNS- LAYWELL
BURIAL
26. LOCATION (CITY, STATE) lot FUNERAL HOME
CREMATION CAMERON, TEXAS s .6. P 0 BOX 225
REMOVAL FROM Fl 27. SIGNATURE OF FUNERAL DIRE R OR PERSON
ACTING AS SUC Unknown 2800 NORTH TRAVIS.
DONATION
28. DATE OF DISPOSITION
OTHER (SPECIFY) i� i� a44: E L 11 9914 6 -2 --2003 CAMERON, TEXAS 76520
30
,GYCER11FYING PHYSICIAN TO THE BEST OF MY KNOWLEDGE DEATH OCCURRED AT THE TIME, DATE, AND PLACE, ANO DUE TO THE CAUSE(S) AND MANNER AS STATED.
MEDICAL EXAMINER ON THE BASIS OF EXAMINATION AND/OR INVESTIGATION, IN MY OPINION, DEATH OCCURRED AT THE TIME, DATE. PLACE, ANO DUE TO THE
JUSTICE OF THE P CE CAUSE(S) AND MANNER AS STATED.
31. SIGNATURE 6 E..OF CERTIFIER 32. DATE SIGNED 33. TIME OF DEATH
M0 DAY O Y 3 11:00 M.
3•. PRINTED AMEB ADDRESS CERTIFIER
ks WO /4 a
t /o I Soma 31s 71
F a
35. PART 1 ENTER THE DISEASES. INJURIES OR COMPLICATIONS THAT CAUSED THE DEATH. OO NOT ENTER 1(48 MODE OF DYING SUCH AS APOrvaima10
Interval Between IMMEDIATE CAUSE CARDIAC OR RESPIRATORY ARREST, SHOCK, OR HEART FAILURE. UST ONLY ONE CAUSE ON EACH LINE. .1 and DBM
no, I n,fNe /1.- z� r m
a condition resulting 6 death) DUE 10 (OR AS A LIKELY CONSEQUENCE OF):
g b.
Sequentially Nat conditions, II any. DUE TO (OR AS A LIKELY CONSEQUENCE OF):
leading 101mm.d'Nls cause. Enter
UNDERLYING CAUSE (Qa
ss. 0.
u. a blasted wools DUE TO (OR AS A 14(61.1 CONSEQUENCE OF):
resulting A1 daUi) LAST
j PART2 OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING IN THE UNDERLYING I36a. AUTOPSY? 36b. AUTOPSY FINDINGS AVAILABLE
YES O 565 NO
g CAUSE GIVEN IN PART 10.0, W
substance *ruse, d3W1.s.srnddn6,.6.) PRIOR TO COMPLETION OF CAUSE OF
DEATH?
G
p 37. DID TOBACCO USE f•- C TO DEATH 38. DID ALCOHOL USE CONTRIBUTE TO DEATH 39. WAS DECEDENT PREGNANT
YES 0 PROBABLY 1 YES PROBABLY AT TIME OF DEATH ❑YES 0 LINK
..a.. ,UNKNOWN L „ONO I 1 UNKNOWN WITHIN LAST 12 MO YES NO LINK
40 MANNER OF DEATH 11a. DATE OF INJURY I 410. TIME OF INJURY 41G INJURY Y AT WORK NO ETC (PELF INJURY -AT HOME FAfW, STREET. FACTORY, OFF/CE,. N M.
ATURAL 111
ACCIDENT 110. LOCATION (STREET AND NUMBER, CITY OR TOWN, STATE)
b i
O SUICIDE
HOMICIDE 111. DESCRIBE HOW INJURY OCCURRED
W PENDING INVESTIGATION
N ❑CWLD NOT BF DETERMINED
12.. REGISTRNL FILE N0. 42).. DATE RECEIVED BY LOCAL REGISTRAR 421. SIGNATU F L AL REGISTRAR L f7 z q Of /9 7.003 06 -lC 2_603 I !ll a-, P 3 ?7
DATE ISSUED:: 2
COUNTY OF MILAM
CERTIFICATE OF DEATH. STATE FILE NUMBER
MILAM COUNTY, TEXAS
THIS IS TO CERTIFY THAT THIS IS A TRUE AND CORRECT REPRODUCTION OF THE ORIGINAL RECORD AS RECORDED: IN THIS OFFICE.
ISSUED UNDER AUTHORITY OF SECTION 191.051, HEALTH AND SAFETY CODE.
PROPERTY NUMBER
DECK NUMBER
AMOUNT OF OWNERSHIP
INTEREST
001079 -000
11
0.00005842
15
0.00005842
23
0.00005842
25
0.00005842
001541 -000
15
0.00005842
25
0.00005842
35
0.00004135
001542 -000
15
0.00005 842
25
0.00005842
001543 -000
11
0.00005842
15
0.00005842
21
0.00005842
25
0.00005842
001544 -000
15
0.00005842
001578 -000
15
0.00005842
25
0.00005842
002413 -000
15
0.00005842
002414 -000
15
0.00005842
002415 -000
11
0.00005842
15
0.00005842
002418 -000
15
0.00005842
002422 -000
15
0.00005842
002423 -000
15
0.00005842
002425 -000
15
0.00005842
25
0.00004135
002426 -000
15
0.00005842
002427 -000
11
0.00005842
15
0.00005842
002428 -000
15
0.00005842
002429 -000
15
0.00005842
"EXHIBIT B"
JOAN RYAN MOORE'S OWNERSHIP INTEREST
IN EOG RESOURCES, INC. INHERITED BY JACK ELWIN MOORE,O 0 0 7 3 8
(OWNER NO. 080527)
Exhibit B
JOAN RYAN MOORE'S OWNERSHIP INTEREST IN EOG RESOURCES, INC. INHE
BYJACKELWIN MOORE (OWNER NO. 080527)
Page 1 of 8
002435 -000
15
0.00005842
25
0.00004135
002437 -000
11
0.00005842
15
0.00005842
002451 -000
15
0.00005842
002454 -000
15
0.00005842
25
0.00004135
002455 -000
15
0.00005842
002456 -000
15
0.00005842
002491 -000
15
0.00005842
25
0.00004135
004637 -000
15
0.00005842
25
0.00004135
004638 -000
15
0.00005842
25
0.00004135
004639 -000
15
0.00005842
004640 -000
15
0.00005842
004641 -000
11
0.00005842
15
0.00005842
004642 -000
15
0.00005842
004643 -000
15
0.00005842
004645 -000
11
0.00005842
15
0.00005842
22
0.00004135
25
0.00004135
004646 -000
15
0.00005842
25
0.00005842
35
0.00041667
004649 -000
15
0.00005842
25
0.00005842
004650 -000
15
0.00005842
004651 -000
15
0.00005842
25
0.00005842
004652 -000
15
0.00005842
25
0.00005842
Exhibit B
JOAN RYAN MOORE'S OWNERSHIP INTEREST IN EOG RESOURCES, INC. INHERITED
BY JACK ELWIN MOORE (OWNER NO. 080527)
9f 8
000739
Exhibit B
JOAN RYAN MOORE'S OWNERSHIP INTEREST IN EOG RESOURCES, INC. INHERITED
BY JACK ELWIN MOORE (OWNER NO. 080527)
Page 3 of 8
000740
004653 -000
15
0.00005842
25
0.00005842
004654 -000
15
0.00005842
25
0.00005842
004655 -000
15
0.00005842
25
0.00005842
004656 -000
11
0.00005842
15
0.00005842
21
0.00005842
25
0.00005842
004657 -000
15
0.00005842
25
0.00005842
004658 -000
11
0.00005842
15
0.00005842
21
0.00005842
25
0.00005842
33
0.00004135
35
0.00004135
004662 -000
15
0.00005842
25
0.00005842
004663 -000
15
0.00005842
25
0.00005842
004664 -000
15
0.00005842
25
0.00005842
004665 -000
15
0.00005842
25
0.00005842
004666 -000
15
0.00005842
25
0.00005842
004667 -000
15
0.00005842
25
0.00005842
004669 -000
15
0.00005842
004670 -000
11
0.00005842
15
0.00005842
21
0.00005 842
25
0.00005842
019808 -000
15
0.00005842
25
0.00005842
35
0.00004135
Exhibit B
JOAN RYAN MOORE'S OWNERSHIP INTEREST IN EOG RESOURCES, INC. INHERITED
BY JACK ELWIN MOORE (OWNER NO. 080527)
Page 3 of 8
000740
022076 -000
15
0.00005842
25
0.00004135
022077 -000
15
0.00005842
25
0.00005842
35
0.00004135
022079 -000
15
0.00005842
022093 -000
15
0.00005842
022094 -000
15
0.00005842
022095 -000
15
0.00005 842
25
0.00004135
022096 -000
15
0.00005842
025151 -000
15
0.00005842
25
0.00004135
026145 -000
25
0.00009402
026148 -000
13
0.00009401
15
0.00009402
026161 -000
14
0.00009401
15
0.00009402
026163 -000
13
0.00009401
15
0.00009402
026168 -000
13
0.00009401
15
0.00009402
026175 -000
13
0.00009401
15
0.00009402
026178 -000
13
0.00009401
15
0.00009402
026749 -000
15
0.00009402
17
0.00009401
026750 -000
15
0.00009402
027322 -000
13
0.00009401
15
0.00009402
027326 -000
13
0.00009401
15
0.00009402
Exhibit B
JOAN RYAN MOORE'S OWNERSHIP INTEREST IN EOG RESOURCES, INC. INHERITED
BY JACK ELWIN MOORE (OWNER NO. 080527)
Pn" 4 o f8
000741
027646 -000
15
0.00009402
19
0.00009401
028612 -000
13
0.00009401
15
0.00009402
028758 -000
15
0.00009402
18
0.00009401
028759 -000
15
0.00009402
19
0.00009401
028866 -000
15
0.00009402
19
0.00009401
029478 -000
15
0.00009402
17
0.00009401
029479 -000
15
0.00009402
17
0.00009401
029483 -000
15
0.00009402
17
0.00009401
030096 -000
15
0.00009402
18
0.00009401
030139 -000
15
0.00009402
17
0.00009401
030220 -000
15
0.00009402
17
0.00009401
030228 -000
15
0.00009402
17
0.00009401
030727 -000
15
0.00009402
17
0.00009401
030729 -000
15
0.00009402
17
0.00009401
031826 -000
13
0.00009401
15
0.00009402
031828 -000
13
0.00009401
15
0.00009402
031830 -000
15
0.00009402
17
0.00009401
031831 -000
13
0.00009401
15
0.00009402
Exhibit B
JOAN RYAN MOORE'S OWNERSHIP INTEREST IN EOG RESOURCES, INC. INHERITED
BY JACK ELWIN MOORE (OWNER NO. 080527)
Page 5 of 8
000742
Exhibit B
JOAN RYAN MOORE'S OWNERSHIP INTEREST IN EOG RESOURCES, INC. INHERITED
BYJACKELWIN MOORE (OWNER NO. 080527)
P of8
00743
031839 -000
13
0.00009401
15
0.00009402
031840 -000
15
0.00009402
17
0.00009401
031841 -000
15
0.00009402
17
0.00009401
031842 -000
15
0.00009402
17
0.00009401
031843 -000
13
0.00009401
15
0.00009402
031846 -000
13
0.00009401
15
0.00009402
031847 -000
13
0.00009401
15
0.00009402
031849 -000
13
0.00009401
15
0.00009402
031850 -000
13
0.00009401
15
0.00009402
032046 -000
15
0.00009402
032688 -000
13
0.00009401
15
0.00009402
032784 -000
13
0.00009401
15
0.00009402
033056 -000
13
0.00009401
15
0.00009402
033344 -000
13
0.00009401
15
0.00009402
033346 -000
13
0.00009401
15
0.00009402
033347 -000
11
0.00041667
15
0.00041667
033348 -000
13
0.00009401
15
0.00009402
033497 -000
13
0.00009401
15
0.00009402
Exhibit B
JOAN RYAN MOORE'S OWNERSHIP INTEREST IN EOG RESOURCES, INC. INHERITED
BYJACKELWIN MOORE (OWNER NO. 080527)
P of8
00743
Exhibit B
JOAN RYAN MOORE'S OWNERSHIP INTEREST IN EOG RESOURCES, INC. INHERITED
BY JACK ELWIN MOORE (OWNER NO. 080527)
Page 7 of 8
00744
033501 -000
15
0.00009402
17
0.00009401
033502 -000
13
0.00009401
15
0.00009402
033503 -000
15
0.00009402
17
0.00009401
033506 -000
13
0.00009401
15
0.00009402
033507 -000
13
0.00009401
15
0.00009402
033509 -000
13
0.00009401
15
0.00009402
038468 -000
11
0.00009401
15
0.00009402
038469 -000
15
0.00009402
19
0.00009401
051501 -000
13
0.00009401
15
0.00009402
052680 -000
11
0.00009401
15
0.00009402
057102 -000
15
0.00005843
057105 -000
15
0.00005843
057106 -000
15
0.00005843
057107 -000
11
0.00005843
15
0.00005843
057178 -000
12
0.00005843
15
0.00005843
057179 -000
11
0.00005843
15
0.00005843
058037 -000
21
0.00009401
25
0.00009402
058161 -000
12
0.00005843
15
0.00005843
058395 -000
15
0.00005843
Exhibit B
JOAN RYAN MOORE'S OWNERSHIP INTEREST IN EOG RESOURCES, INC. INHERITED
BY JACK ELWIN MOORE (OWNER NO. 080527)
Page 7 of 8
00744
Note: The approximate net value of the total production for all wells each year is
$1,565.64, which is dependent upon production.
Exhibit B
JOAN RYAN MOORE'S OWNERSHIP INTEREST IN EOG RESOURCES, INC. INHERITED
BY JACK ELWIN MOORE (OWNER NO. 080527)
Page 8 of 8
00745
058396 -000
15
0.00005843
058428 -000
11
0.00005843
15
0.00005843
058468 -000
11
0.00005843
15
0.00005843
060430 -000
15
0.00005843
060431 -000
15
0.00005843
060432 -000
15
0.00005843
Note: The approximate net value of the total production for all wells each year is
$1,565.64, which is dependent upon production.
Exhibit B
JOAN RYAN MOORE'S OWNERSHIP INTEREST IN EOG RESOURCES, INC. INHERITED
BY JACK ELWIN MOORE (OWNER NO. 080527)
Page 8 of 8
00745