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Home My WebLink About962788AFFIDAVIT FOR DISTRIBUTION WITHOUT PROBATE The State of Wyoming ss. County of Lincoln COME NOW Janet Conroy, Robert Dennis Conroy, and Matthew Carl Conroy, and after having been duly sworn upon their oath, depose and say as follows: 1. David Clifton Conroy, also known as David C. Conroy and David Conroy, died on July 3, 2011 in Salt Lake City, Salt Lake County, Utah. At the time of his death he was thirty -six (36) years of age, was a resident of the State of Wyoming and resided at P.O. Box 216, Diamondville, Wyoming 83116. 2. The value of decedent's entire probatable estate, wherever located, less liens and encumbrances, does not exceed 150,000.00. 3. More than thirty (30) days have elapsed since the death of decedent. 4. No application for the appointment of a personal representative is pending or has been granted in any jurisdiction. 5. Decedent died without a will. The individuals named hereinbelow are the surviving mother, surviving father, and surviving brother of decedent and are the sole heirs of the decedent under Wyoming's laws of descent and distribution. There are no other distributees of the decedent having a right to succeed to the property under probate proceedings or under the laws of descent and distribution in the State of Wyoming or any other state: a. Janet Conroy, mother of decedent, of legal age, P.O. Box 216, Diamondville, Wyoming 83116; b. Robert Dennis Conroy, father of decedent, of legal age, P.O. Box 216, Diamondville, Wyoming 83116; and c. Matthew Carl Conroy, brother of decedent, of legal age, P.O. Box 216, Diamondville, Wyoming 83116. The above -named distributees are entitled to payment or delivery of all accounts and property which belonged to the decedent. 6. By their signatures hereon Janet Conroy, Robert Dennis Conroy, and Matthew Carl Conroy hereby specifically request that the property, accounts, debts, obligations, and investments specifically named hereinbelow authorized by Wyoming Statute 2 -1 -201 to be distributed by affidavit be made payable and or delivered and /or set over to Janet Conroy. Said property, accounts, debts, obligations, and investments are more particularly described as follows: a. Benefit Payable, in the amount of five thousand one hundred and twelve dollars ($5,112), to Decedent from CIGNA Group Insurance, Account 5076090, Plan /Policy FLK 0980049, Incident Number 2346563, Plan /Policy Holder Halliburton Energy Services, Inc. /T. Haynes. b. Any Benefits Payable to the Estate of Decedent from CIGNA Group Life Insurance which are due to said Estate as a result of the Decedent's death, including but not necessarily limited to Life RECEIVED 1/17/2012 at 4:22 PM RECEIVING 962788 RnnK: 779 PAGE: 413 JEANNE WAGNER 00413 Insurance Benefits, Long Term Disability Benefits, and Survivor Benefits, Plan /Policy Number FLK0980049, Plan /Policy Holder Halliburton Energy Services, Inc. /T. Haynes. c. Any interest Decedent had at the time of his death in any investment accounts with Fidelity Investments, Account Number X39 897876. d. Any interest Decedent had at the time of his death in a Halliburton City Card Services Account, with an attendant Debit Card for said Account having the identification number of 4801 -5100- 3048 -6261. 7. The affiants, Janet Conroy, Robert Dennis Conroy, and Matthew Carl Conroy, are signing this affidavit for the purpose of distributing the assets of the estate in accordance with the intestacy laws of the State of Wyoming, and in accordance with the agreement of the affiants as to how said property, accounts, debts, obligations, and investments should be set over. 8. Any person or institution transferring property of the decedent in accordance with this affidavit shall be held harmless and a receipt from any distribute is a valid and sufficient release and discharge for any such person or institution in regard to transferred property. 9. This affidavit is made in compliance with W.S. 2 -1 -201. 10. A certified copy of the Certificate Of Death is attached hereto and by this reference made a part hereof. DATED this /7 day of 0 20 /Z. atthew Carl Conr The State of Wyoming County of Lincoln The forgoing Affidavit for Distribution Without Probate was acknowledged, subscribed and sworn to before me this AIL day of hoart1r 20 G i by Janet Conroy. Witness my hand and official seal. My Commission Expires: 03/42- ss Li 1 711'3 Robert Dennis Conroy C A 07)Ag tivc._ Notary Public -2- -ULU SAVANNA L. KRALL NOTARY PUBLIC COUNTY OF OF L''' LINCOLN WYOMING CI!;:;;;�' My Commission Expires 00414 The State of Wyoming ss. County of Lincoln The forgoing Affidavit for Distribution Without Probate was acknowledged, subscribed and sworn to before me this fl day of aft 20 12- by Robert Dennis Conroy. Witness my hand and official seal. My Commission Expires: The State of W County of M� ss. 00415 Notary Public SAVANNA L. KRALL NOTARY PUBLIC COUNTY OF STATE OF LINCOLN J y WYOMING xp C My Commission Expires V 17/71(1 The forgoing Affidavit for Distribution Without Probe was y.eknowledged, subscribed and sworn to before me this day of de( 20_4Z_, by Matthew Carl Conroy. Witness my hand and official seal. My Commission Expires: otary °ublic ar- ro(4 4/ /v .00 /5 .1vNIV VFW kI -i'-'11M.,741$10 ttittsfitaa----7voAost,ttoR•D"'•,rY' 7 FPS DECEDENT OR1VIATION Date of Death: July 3, 2011 `City of Death: Salt Lake City 36_ Priria r 11=271 No 5006. sffan.IT; -za lildtisiry/Bblinb Residence: Diamondville, Wyoming Mother's Name: Janet Lee Clark Facility orrAddrDssi- SaltLakeRegional. Medical Centef DISPOSITION INFORMATION Method of Disposition:. Removal P_Iace QThiri -4-4- Date ofiOiSp2dAili& r FUN ERA1.4t1:0ME1NECMMARON_-_==.1=== ir MEDICAL CtI101■1 7z: ect412FL Wililam PAUSE OP rbat6 Issiird!JUIS7 2011 Haliburton In. V-7" 4 ".1;tr Time of Death: 17:48 County of Death: Salt Lake Dat -E Bitta :-June23, 195 Sex Mari: pusM art Educatrok ghhrGED Father's Name: Robert Dennis Conroy Facility Type: Hospital Inpatient 1 _N: P PRMANT kit A i RI■liAT I 0 N 42.4 Lt,_.'r 7= prtre:: '-'7F_ -1-1=17.-T7 Rokertl27erinii Conroy -ik r_-,: _W R e a t R5 rtgfi rail-W r■ddiTeg P.071 216, D151 Funeral Horne: Crahtlall Funeral Home Address: PO Box 5, 105 East Center Street, Kamas, Utah 84036 Funeral Director: Gregory J_Crandall sk Acinetobacter pneumonia Due to (or as a consequence of): Aspiration pneumonia 1:)its (Opas a,cpr_A of): Pancreatitis due to gallstone with post-op aspiration T1co Use Nonr-taar Medical Examiner Ooltitactedi--Y.eS' Autopsy:-E?eitamedf No gManri eli Of= bath: 4fo2 ."-f This is anlexactl•repeociuction OLthe.490iment regikteratf of Vital)Statistiosil L 1 OF,j.kr.4. aragagsal Security features of this offiCial Op cycloids; HS ultra fibers and hologram iniage.iotthe Utah Sfa th Ofilltah". 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