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HomeMy WebLinkAbout961292STATE OF WYOMING ss. COUNTY OF LINCOLN AFFIDAVIT FOR DISTRIBUTION OF DECEDENT'S PERSONAL PROPERTY PURSUANT TO W.S. S 2-1-201 We, DIANNE LYNN PARK and FRANK F. HILL, III, children of Frank F. Hill, Jr., being first duly sworn, on oath depose and state that we are making this Affidavit pursuant to W.S. 2- 1 -201, on behalf of ourselves as distrbutees, as hereinafter set forth. that we make the following statements in connection therewith: 1 On or about November 25, 1994, PATRICIA A. IIILL, wife of Frank F. Hill, Jr., became deceased as is evidenced by the official Certificate of Death attached hereto as Exhibit "A" and incorporated by this reference. 2. On or about January 11, 2011, our father FRANK F. i1ILL, JR. became deceased as is evidenced by the official Certificate of Death attached hereto as Exhibit "B" and incorporated by this reference. 3. At the time of his death, our father owned certain personal property with his wife, PATRICIA A. HILL, said personal property being located in the County of Lincoln, State of Wyoming, and more particularly described as follows: 1993 Ford VIN 1FMDU34X8PUE06525, titled in the names of Hill, Frank F. or Patricia A., in joint tenancy with right or survivorship and not as tenants in cominon. 000886 A copy of this vehicle title is attached hereto as Exhibit "C" and incorporated by this reference. 4. By reason of the death of PATRICIA A. HILL, our father was entitled to sole ownership of the above mentioned personal property. 5. By reason of the death of our father, DIANNE :LYNN P ©RK and F n NTT F. HILL, III, children Frank F. Hill, Jr., are entitled to joint ownership of the above mentioned personal property. Affidavit for Distribution Page 1 of 2 RECEIVED 10/6/2011 at 1 0:29 AM RECEIVING 961292 BOOK: 773 PAGE: 886 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY COUNTY 0 EXECUTED this .2.3 day of OF F I Cylci,._... p COUNTY OF 1 .cic.l STATE OF SC�L1/47,A,?"A—. My Commission Expires: SUBSCRIBED AND SWORN to before rne, a Notarial Officer, by DIANNE LYNN PARK this 23 day of Scel 2011. NOTARY PUBLIC -STATE OF FACITARIAL OFFICER F.lten. M. Berke My Commission Expirb Cum :rz_:: ion 1)933297 ;EC, C.3, 2 413 BONDED TOO AT NTI.; BONDING CO., INC. ss. COMMONWEALTH OF PENNSYLVANIA Notarial NOTAR L OFFICER Se Beverly A. Thompson, Notary Public City of Harrisburg, Dauphin County My Commission Expires April 16, 2014 Member, Pennsylvania Association of Notaries Affidavit for Distribution Page 2 of 2 ,2011. n /V DIANNE LYNN PARK Address: 761 Whippoorwill Ter. West Palm Beach, FL 33411 FRANK F. HILL, II1 Address: 513 Maple Rd. Middletown, PA 17057 SUBSCRI D AND S ORN to before me, a Notarial Officer, by FRANK F. HILL, III this y of `1' 2011. 000887 1105.112 REV. 8 -88 'EE FOR THIS :ERTIFICATE $2,00) CERT. NO. 2395890 Name of Decedent Sex Female Social Security No. Date of Death NnvPmber 25, 1994 Date of Birth '/17/1931 Birthplace Mi ddl Pt PA Place of Death Harri shura Hnap_i_ ±al Diu•. H. Penns Ivania Facility Nam County City, Borough or To unship Race White Occupation Tel ler- Banking Armed Forces? (Yes or No) Decedent's Marital Status Mar ried Mailing Address P Nu 0 mber R °x St' eat W y o "'c y go $31 27 own State Informant Frank ,T Hil 1 ,Tr Funeral Director Paul L. Gardner Name and Address of Funeral EstablishmentCnh1P RPher F_H_ Inn.. 208_N... tJninn St.. Middletown, PA 17057 Interval Between Part I: Immediate Cause Onset and Death (a) Metastatic- Colorectal___Cance.r (b) Sepgi (c) a m• I (d) Part II: Other Significant Conditions Manner of Death: Natural )X Homicide Accident El Pending Investigation Suicide El Could not be Determined El vvmrsni 1VU: 11 1, ILLtuAL 10 AL I tH 11115 COPY OR TO DUPLICATE BY Pr ,.'..w TAT OR PHOTOGRAPH. COMMONWEALTH 01- PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS LOCAL REGISTRAR'S CERTIFICATION OF DEATH PATRTCT73 7 HTT,T, First Middle Name and Title of Certifier Andrew Ri rds M D Address 1511 N Frnnt StrPPt.. Harrisburg, PA NovemhPr 28, 1994 Date Received by Local Registrar Describe how injury occurred: This is to certify that the information here given is correctly copied from an original certificate of death duly filed with me as Local Registrar. The original certificate will be forwarded to the State Vital Records Office for permanent filing. 2 /�ZC��Ci/ 22-926 Local Registra of Vital ecords District No. November 28 1994 Date of Issue of This Certification Last 000888 Nn (M.D., D.O., Coroner, M.E.) 12��uc�,St.. Middletown. PA 17057 Street Address City, Borough, Township 1. Name of Decedent (First, middle, last, suffix) Frank F. Hil Jr, 2. Sex M 3. Social Security Number 4. Dale 01 Death (Month, day, year) 1/11/11 5. Age (last Birthday) 86 ye Under 1 year Under 1 day 6. Dale al Birth (Noah, day, year) 7. Birthplace (City and slate or for Mn country) 8a. Place of Death (Check only one) Mantas Days Noun Mingles 6/26/24 Middletown, PA Hospital: lnpalio I ER Outpatient DOA Other. El Nursing Home Residence ['Other Specify: 8b. County al Death Dauphin 8c. C y, Boro,Twp of Death Harrisburg 8d. Facility Name (II not Institution, give skeet and number) Ecuminical Community Inc. 9. Was D cadent al Hispanic Origin ik] No Yes (If yes, pacify Cuban, ��cc Mexican. Puerto Rican, etc.) 10. Race: American Indian, Black, White, etc. (Specify) White 11. Decedents Usual Occupation (Kind of work done urine most of working life. Do not slate relined) 12. Was Decedent ever in the U.S. Armed Forces? ❑vent 13. Decedent's Education (Specify only highest grade completed) 14. Marital Maros: Marred, Never Married, Widowed, Divorced Specfy) Widowed 15. Surviving Sp use (11 wife, give maiden name) Kind of Work Contractor Kind of Business I Industry Concrete Elementary I Secondary (0.12) 12 1 College (1 -4 or e) 16. Decedents Meiling Address (Street, city /town, ale, zip code) 386Dogwood Drive Star Valley Ranch, Wyoming 83127 18. Father's Name (First, middle, last, suffix) Frank F. Hill Sr. Decedent's Did Decedent Live in a 17c. Yes, Decedent Lived it Twp Actual Residence 17a. Slate Wyomir g Townshg ,>b. County' L incoln 174. oecedenl184 Ac tual Umila of Star Valley panel, City /Bore 19. Mo6mr's Name (HrsL middle, maiden sumame) Marion Durborw 20a, Informant's Name (Type Print) Fria k F. Hill TTT 205. Informant's Mating Address (Street, city town, slate, zip code) 513.Manle Rd. Middletown, PA 17057 218. Method of Disposition Burial Removal hom Stale nmer Spedy: Cremation ❑Donation Was Cremation or Donation Aulhorizad by Medical Examiner/Coronen ❑vee ❑Na 21b. Dale of Disposition (Month, day, year) 1/1 21. Pace of Disposiion (Name of cemetery, crematory or other place) Paddletown Cemetery 21d. Location (City flown, stale, alp rode) York County 22a. Signsre�,e Funeral Service Licensee (m pemu acting as such) s..% .114A4e, C NAN/ 22b. License Number 0- 10098 -L 22c. Name and Address a Fadfity Matinchek Daughter Funeral Home Middletown, PA 17057 Complete Items 230.0 only when cedflying physician nor available le al Ume of death to cad* ceass e of deeath. a 23a. T m0 esl of my knowledge, death Occurred of ���UUleee Bme, date nd place stated. (Signature and ate) G( -��C- �,S( r �r� v J 23b. License Number /l S O 23c. Dale Signed (Month, day, year) a -A c,263 Items 24-26 must be completed by person who pronounces death. Death r 4,... 25. Prorwunced Dead (Month, day, year) e a 26. Was Case Referred to Medical Fxa ran I Yes e Reason Other Met Cremation or Oonallon? CAUSE OF DEATH (See Instnictio s a d examples) j J Item 27. Part It Enter the chain of events diseases, injuries, or compgwlions- Ihal dredly caused the Ih DO NOT enter le0nma events such as cardiac arrest, Approximate interval: Onset to Death 6 1 41D Pad I Enter other sionilicant condibns co0nbukne to death but rat result In the undedying cause Oven in Peril, 28. Did Tobacco Use Contribute to Death? Yes Probably �'No ❑Unknown respiratory arrest, or venlricule i6lllation without slowing the 811010gy.. List only one cause on each line. 1558 1 re CAC ia deal,) ✓l e 1 1"h U condAo ATECAU9E (Fin9l msea or A t. AtT t C o.. C tQJC 29. If Female: Due to (or as a consequence of): Sequentially IM conditions, if any, b to 1 8078400 tae �1 LL,, L�`i" I P) n Not pregnant wllhln past year Pregnant al lime of death Enter g 0 00000 a. Ever 9l0 UNDERLYING CAUSE Due to (or as a consequence 0l5 evenk resu111R0 m dealh� at,ST e o 1( I O Nol pregnant, but pregnant within 42 days of death Due to (or as a consequence el): d Nol pregnant, but pregnant 43 days to 1 year before death 30a. Was an Autopsy Pedormed7 Yea )211 30b. Were Autopsy Rndngs Available Prior to Completion of Cause d Death? Yes No 31. Manner of Death rural Homicide 320. Dale of Injury (Month, day, year) 32b. Describe How injury Occurred Unknown 11 pregnant within the past year 32c. Place d Injury; Homo a Farm, Street, Factory, Office Buikfng, le (Spa ryj Accident Pending Investigation Suicide Could Not be Oeterrmned 32d. Time of Injury M 32e. Injury at Work? Yes No 321.11 Transportation Injury (Specify) a' er/ Operator ❑Passenger ❑Pedestrian Daher Specify: 32g. Location al Injury (Skeet, 06 1 lawn, slate) 330, Certifier (check 001 one) Certifying ph slclan (Physician cedilying cause of death when another physician has pronounced death nd completed Item 23) To the best of my knowledge, death occurred due to the cause(s) and manner as slated_ Pronouncing not cedltyfng physician (Physician bolh pronouncing death and cedilying to cause of death) To the best of my knowledge, death accused at the lime, date, and place, and due to INC eause(0) and Mannar •s stated Medical Exam ner /Coroner 0n the basis I examination and or investigation, In my opinion, death occurred at the lime, date, and place, and due W the cause(s) and manner as stater_ 33b. e d dig q(Ced 4 I 1r' e 33e. License Number 0 5 0 0 d 0 S S d an ay, year) 37tl 1 Dale 1 l 34 Na a I Perse mpIgled Ce eath ape I P I N Y r: QI W�•'`.XI QI' u V 1 vrirbur5 �A I7I DI 35 R egistrar's Signal District Nu er n °L �Zc 1e�uj i I 36. Dale Filed (Month day, year) a -a�a r( 'CC: 1'01 1111 Y'(111)1:;)) v �,(1{} 6105 -143 REV 11/2006 TYPE PRINT IN PERMANENT BLACK INK z 0 0 0 P 17246305 )ill)' l)llnl hl1ilnhl•r LOCAL BE WARNING: le Disposition Permit Na. 0 '-1/ Ca (J ON D TH or lafi 1.,,u' ;Crfa. COMMONWEALTH OE PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS CERTIFICATE OF DEATH (See Instructions and examples on reve se) STATE FILE NUMBER 000889 Hrj h11 1 i t?dl1Gi1i(111 1 1 11} Ord t 1'711 :<1)(` /11'; l'S'C,It:lr li' IlliP1110 i(1 I(1 r ;In)t' fl'1 ly(`t ltu:ll lf'1il ilh ll:�. a uJ t-- FACTORY PRICE STATE ,:p..Rioe TITLE NO iSELLER s NAR $21 I A 60 NA 11 UTAH•i' OWNER FST-301 (MN) HILL, FRANK k. ORFkATRLC BOX 766 12 OFFICE OF COUNTY CLERK WYOMING KEEP IN A SAFE RLACE ANY ALTERATION TITLE NUMBER FEE 6.00 DATE ISSUED R, TIFICATE OF TIT VEHICLE•LADENTIEICATiolTNO:i":-T 800Y STYLE OnIy D EUEL 9 1 0/ 01 /9 3 _NE' 7 1. :N JotILf YA44371-1: RIGHT )R 6URVIVOF9H1P ........It74:..gomme.4MOT-A,' FURCH. DATE 9/14/93 7: '-'1. --:'-.;1N :1NITNES WHP9F9E,1114■/6*iortinto Certit- ---:i ii_i date-;-t.:be;8igned oncl. ',sod b of „this office to e-, OladOttAfietO011., r 3 7 .7- -County Clerk (Date) 12 EXHIBIT C./ 000890 USED County:Clerk '7.: Deputy (Date) 1. (SEAL) Second Lien Released:. :Deputy:: (Date) T. Clerk (SEAL) (SEAL) 0840520