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Home My WebLink About964278Summary Probate Procedure Affidavit Wyo. Stat. Ann 2 -1 -201 202 (2007 LexisNexis) Conies Now, c cis S u11. �I� k and pursuant the above referenced Wyoming Statutes state as follows: 1) That A r 23- 0 C of S R‘1'1 Kemmerer, WY passed away in Lincoln County Wyoming on the 1`t day of t` J 20 0 w 2 2) The value of the entire estate, wherever located, less liens and encumbrances, does not exceed 0 N W W one hundred fifty thousand dollars ($150,000.00) Wyo. Stat. Ann. 2 201 (a) (i) (LexisNexis N LLJ Z Y 2007). CD Q C7 Q 0_ J 3) Thirty (30) days have elapsed since the death of the decedent. Wyo. Stat. Ann. 2 201 (a) (ii) W U (LexisNexis 2007). Z Z 0 4) No application for appointment of a personal representative is pending or has been granted in U any jurisdiction. Wyo. Stat. Ann. 2 -1 -201 (a) (iii) (LexisNexis 2007). 5) That C i�ck�sS \VT�- -hS ON (claiming distributee) is an adult and is entitled to Z payment or delivery of estate property and there are no other distributees of the decedent having a right to succeed to the property under probate proceedings Wyo. Stat. Ann. 2 -1 -201 (a) (iv) (LexisNexis 2007). 6) Applicable Wyoming statutes are hereby attached to and incorporated herein by reference. 7) Specifically as to vehicles, I, name above, hereby request and desire that title to the vehicle(s) listed below be titled in the name of W N\ a) b) c) Dated this 6 day of AVM 1' STATE OF WYOMING SS COUNTY OF' LINCOLN `fi On the j 7 day of e- 1" 20 Il, x d F' 'roc a' appeared before me, in person, and execu d this Summary Probate Procedure Affidavit. LuAann yd Cor••uirii� dOTAR PUBLIC i COUNTY p O� F /y SS tT, STATE 1 O p� F LI Bll�atn�LN 1 ✓H bb ai�^ WYV NG Svc. 0mmKNssraDARES in MARY 7, 2015 a: 201,2 \�CLY 0 dtUS 1 4Xli )(kc()(\ (Print Name) Claiming Distributee Notary Public My Commission Ex ()ADM 00236 4r l 1 111 DATE FILED BY STATE REGISTRAR: rl')I� DATE ISSUED: STATE OF IDAHO IDAHO DEPARTMENT OF HEALTH AND WELFARE BUREAU OF HEALTH POLICY AND VITAL STATISTICS State of Idaho CERTIFICATE OF DEATH STATE FILE NO. wsEO SES� =s�wiee DOCUMENT, rACm nioe or.wsoEn WITH im yi•�iegAUO g:i=i,�iioAHO WELFARE oo Local Reg. No. This is a true and correct reproduction of the document officially registered and placed on file with the IDAHO BUREAU OF HEALTH POLICY AND VITAL STATISTICS. This copy not valid unless prepare en engraved border displaying state seal and signature of the Registrar. JANE S. SMITH STATE REGISTRAR 00237 Via.• A ,.11. �r ?��.i.. s XAAAA7Y ATA 7m�7U':DUuYx➢J M olt�rxrw7r aYS Ilds��.��d�:�!�dlBl��al:ay.7tl. 911: 1dMr1a1161 �AId:( �e7dcAaldra. Y, 4d�' f, T11..' ?L \��r._.'- 'y,.ka>'ld /M,R4: FZ\.56„•� "�)llh,. r l'h' ni:A1u$L '811' „il r2 111 l l I l I I I I I I f r!! 1. DECEDENT'S LEGAL NAME (Include AKA's If any) (First, Middle, Last. Suffix) Heidi RaeLynn Kocha. Murdock 2. SEX Female 3. SOCIAL SECURITY NUMBER 40. AGE -Lasl Birthday 33 (Years) 4b. UNDER 1 YEAR 9c. UNDER 1 DAY 5. DATE OF BIRTH (Mei/Day/Yr) September 19, 1973 6. BIRTHPLACE (Clly and Slate, Territory, or Foreign Country). Salt Lake City, Utah months I Days 1 Hours 1 Flnvles 1 7a. RESIDENCE •.STATE OR FOREIGN COUNTRY Wyoming 7b. COUNTY Lincoln 7c. CITY OR TOWN Star Valley Ranch 7d. STREET AND NUMBER 35 Sugar Loaf Circle 70. APT. NO. 7f. ZIP CODE 83127 76. INSIDE CITY LIMITS? El Yes 0 No 8. MARITAL STATUS AT TIME OF DEATH 0 Married 0 Married, but separated 0 Widowed XI Divorced 0 Never married 0 Unknown 9. SURVIVING SPOUSE'S NAME (11 wile. give maiden name) 10. EVER IN U.S. ARMED FORCES? 0 Yes X No 11a. FATHER'S NAME (First. Middle, Last, Suffix) Michael R. Kocha 11b. BIRTHPLACE /Stale, Territory, or Foreign Country) Salt Lake City, Utah l2a. MOTHER'S MAIDEN NAME (First, Middle, Last, Suffix) Linda Joyce Williams 1216. BIRTHPLACE (Stale, Territory, or Foreign Country) Sal Ut h ke City, 130. INFORMANT'S NAME (Type or print) Michael R. Kocha 13b. RELATIONSHIP TO DECEDENT Father 13c. MAILING ADDRESS (Street and Number, City, 5101e, Zip Code) Box 471, T1 Wyoming 83127 14. METHOD OF DISPOSITION 0 Burial 1$cremation 0 Donation 0Entombment O Removal from Idaho 0 Other (Speedy) 15. PLACE OF DISPOSITION (Name and address of cemetery, 16. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY Home P.O. Box 51434 ID 83405 cenelory,otherPlace) Eagle Rock Crematory Idaho Falls, Idaho Wood Funeral 273 N. Ridge Idaho Falls, me c. ym ym 2p Sr CERTIFIER: to Within 72 Hours of Death 17a. SIGNATURE OF FIERAL SERVICE LICENSEE OR PERSON ACTING AS SUCH F e 17b. LICENSE NUMBER (Of licensee) 16. WAS CORONER CONTACTED? M -778 0 Yes 7p No PLACE OF DEATH (19 22) 190. IF DEATHOCCURRED IN A HOSPITAL: I* 19b. IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL: I(Xlnpalienl 00 ER/Outpalient 10 DOA 140 Hospice facility s0 Nursing home /Long term care facility 20 Decedent's hbme 70 Other (Speclly) 20. FACILITY NAME (11 not Meetly, give street and number) Eastern ID Regional Medical Center 21. CITY, TOWN, OR LOCATION OF DEATH, AND ZIP CODE Idaho Falls 83404 22. COUNTY OF DEATH Bonneville, 23, DATE OF DEATH (MO /Oay/Yr) (Spell month) February 19, 2007 24. TIME OF DEATH 25. DATE PRONOUNCED DEAD (Mo /Oay/Yr) (Spell month) 26. TIME PRONOUNCED DEAD 1300 (2001 February 19, 2007 1300 (24hr) 27. CAUSE OF DEATH PART 1. Enter the chain of events diseases, Injuries, or complications that directly caused the death. DO NOT enter terminal events such as cardiac 1 Approximate Interval: I Onset to Death 1 arrest, respiratory arrest. or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause' on a line: IMMEDIATE CAUSE (Final i ti ii deceas or condition DUE TO (or as a consequence o0: Bulling to death) II 1 S conditions, b. ?tit is L LI Y.• 3)r'g t r. ^n �1 IV 1 C�Y r 7 I if any, leading to the cause Du: o(or as o0: I listed on (Inc, Enter the I UNDERLYING CAUSE a I LAST (disease,or Injury DUE TO for as a consequence o0: that Initialed Ihe.evenls resulting In death) d• 1 PART II. Enter other 51nn111cent conditions contribulino Io death but not resulting In the underlying cause given in Pan I 280. WAS AN AUTOPSY 28b. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? No 0 Yes No PERFORMED'? 2 9. DID TOBACCO USE CONTRIBUTE TO DEATH? 0 Yes 0 Probably .f 0 No yq Unknown 30, IF FEMALE (Aged 10.54): ❑Yes 0 Not pregnant within past year 0 Not pregnant, but pregnant 43 days 0 Pregnant al lime of death to 1 year before death 0 Not pregnant. bul pregnant Unknown if pregnant within the p ass within 42 days of death year 31. MANNER OF DEATH IX Natural 0 Homicide 0 Accident 0 Pending Investigation 0 Suicide 0 Could not be determined 32. DATE OF INJURY (Mo /Day/Yr) (Spell month) 33. TIME OF INJURY (24hr) 34. PLACE OF INJURY (Decedent's home, farm, street, construction site, nursing home, restaurant, forest, etc.) 35. INJURY AT WORK? 0 Yes 0 No 36, LOCATION OF INJURY: Slate City/Town or County Zip Code Street and Number or Location Apartment Number 37. DESCRIBE HOW INJURY OCCURRED. IF TRANSPORTATION INJURY, STATE THE TYPE(S) OF VEHICLE(S) INVOLVED (Automobile, pickup, motorcycle, ATV. bicycle, etc.) SPECIFY WHICH VEHICLE DECEDENT 000671E0, 1f applicable TRANSPORTATION i38a. WAS DECEDENT: 0 Driver /Operator 0 Passenger i30b. WHAT SAFETY DEVICES) 010 DECEDENT USE/EMPLOY? INJURY ONLY 1 0 Pedestrian 0 Other (Specify) i 0 Seal bell 0 Child safely seal 0 Helme 0 Air bag 0 None 0 Unknown 39a. CERTIFIER (Check only one, based on,olfici1l capacity for this certificate) e; e N PHYSICIAN To the best of ,ny knowledgalh oc natural cu ed he lime, dale, and place, and due to the n cause(syrnanner staled. 0 CORONER On the basis of examinalloh and /or investigau• n my opinion, death occurred al the time, date, and place, and due to the carnets) and manner slated. Signature and Title of Certifier F 39b. LICENSE NUMBER I Y 1 (D I `I�i I g 1 I 19c. DATE SIGNED ,N Z e M OD YYYY rn' 39d. NAME, ADDRESS, AND 21 CODE OF calms} R (Type or print) Dr. Brent Gree wald, 9200 Channing Way, A -106, Idaho FaJls,._SD834Q4 535- 4H0.0 40a. CORONER'S SUBSEQUENT SIGNATURE IF NECESSARY: The coroner's signature in this item supersedes that of the physician, and the coroner becomes the certifier of record. 40b. DATE SIGNED I have reviewed and d necessary amended the medical section,- MM DD YYYY 11:1*Ni ail:# 41a, REGISTRAR'S SIGN t 1A t TURE n I/ J /il 41b. DATE SIGNED /'/l i'/ X.1 Nl 'I!•'.' Ill.! VI "tGl /2 L l' MM 4r l 1 111 DATE FILED BY STATE REGISTRAR: rl')I� DATE ISSUED: STATE OF IDAHO IDAHO DEPARTMENT OF HEALTH AND WELFARE BUREAU OF HEALTH POLICY AND VITAL STATISTICS State of Idaho CERTIFICATE OF DEATH STATE FILE NO. wsEO SES� =s�wiee DOCUMENT, rACm nioe or.wsoEn WITH im yi•�iegAUO g:i=i,�iioAHO WELFARE oo Local Reg. No. This is a true and correct reproduction of the document officially registered and placed on file with the IDAHO BUREAU OF HEALTH POLICY AND VITAL STATISTICS. This copy not valid unless prepare en engraved border displaying state seal and signature of the Registrar. JANE S. SMITH STATE REGISTRAR 00237 Via.• A ,.11. �r ?��.i.. s XAAAA7Y ATA 7m�7U':DUuYx➢J M olt�rxrw7r aYS Ilds��.��d�:�!�dlBl��al:ay.7tl. 911: 1dMr1a1161 �AId:( �e7dcAaldra. Y, 4d�' f, T11..' ?L \��r._.'- 'y,.ka>'ld /M,R4: FZ\.56„•� "�)llh,. r l'h' ni:A1u$L '811' „il r2 111 l l I l I I I I I I f r!!