Loading...
HomeMy WebLinkAbout965936When recorded mail to: Heather Frazier, CIO Jason D. Smolen,Esq. SmolenPlevy, 8045 Leesburg Pike, 5th Floor Vienna, VA 22182 RECEIVED 8/3/2012 at 3:33 PM RECEIVING 965936 BOOK: 790 PAGE: 731 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY AFFIDAVIT AND ACCEPTANCE OF TRUSTEESHIP Comes now the undersigned Jason D. Smolen and being on oath first duly deposes and says: 1. That I am a citizen of the United States of legal age and capacity, and competent to make this affidavit. 2. That I was personally acquainted with the deceased, Linda A. Miller 3. That said deceased is one in the same person as Linda A. Miller Living Trust, Dated March 26, 2002 listed in that certain document as recorded on April 27, 2012 at Entry No. 964303 in Book 785 at Page 290 in the office of the Lincoln County recorder, State of WY. 4. That the purpose of this affidavit is for Jason D. Smolen, Successor Trustee, to accept the Trusteeship for Mary Elizabeth Villarreal, Co- Trustee of the Article Fourth Trust FBO Heather Frazier U /D /T Linda A. Miller Living Trust Dated March 26, 2002 and hereby agree to act as Trustee of said Trust on all the terms, provisions and conditions specified in said Trust. 5. That a certified death certificate of the deceased is hereby attached. Legal description: ALL OF LOT 89 OF THE ALPINE VILLAGE SUBDIVISION NO. 1 PLAT 2 AMENDED 9TH FILING, LOCATED IN LINCOLN COUNTY, WYOMING, FILED DECEMBER 6, 2006 AS INSTRUMENT #925078 IN THE OFFICE OF THE LINCOLN COUNTY CLERK. Nvvl moviwe, Q5,3 \J■r VIi(i� 75076 MY CO2 A l i /1/1 11111111 1 State of County of 401 ss: ed On 9 July, 2012 personally appeared before meiJason D. Smolen, Successor Trustee, of the Article Fourth Trust FBO Heather Frazier U /D /T Linda A. Miller Living Trust Dated March 26, 2002, and the signer(s) of the within instrument, who duly acknowledged to me that They executed the same. 1 t� R fi VV ��ir k a 0 b N fj y 91 C mm is Expires: Io�l l /6- ?REGIS Z MO (rCP 0031_ Jason D. Smolen, Successor Trustee, Physician/ Medical Examiner Funeral Director 1. Decedent's Name:(First, Middle, Last)'. Li Ann Miller 4a, Facility Name (if not i rstitutioh street and numbed 5401 Bradle Blvd 5. Social Security:Numbe'r 10 ate .orida_ 11,'MaritahStatus 1: Never Married 2 R ❑'Widowed' 4 Divorced'. Elernentary/Seconday (0-12) IF FEMALE: 23b. Was.decedent.pre9nent imthe past 12.inonths4.: 1 ❑,Yes 21$No 9 ❑:uhknown.': 25. Was case referred to medical examiner? 1 Yes 2 1No :10b; County Bxoward Nieetejemetwit: 10e. Street and Number 2108 SE- 23st Street 27. Manner of Death. 1 .Natural ``5 ❑'Pending 2 LJ Accident' Investigation 3 Suicide .6 Coutd hot be 4 ❑:;Homicide determined 12. Was Decedent Ever in U.S. Armed Forces? 1 Yes :2 R :No If Yes, Give. Year or Dates. 15. Decedent's Education:' (Specify only.Kghest grede.complered). College (1 -4 or 5 2 19a. I'nformant's Nanie/Retationship (fype,;Rrint) Heather Frazier /dau•hter .20a. Methodof Disposition' 1 Burial 2,taCremation 3,U :Removal from State 4 Donation 5 :0 othe(: (specify) F 7•: Age`(ln yrs. lastbirthday) Yrs 3. Time of Death ''8:30A 4c. County of Death M©nt•ome 9. Birthplace (State or Foreign Wa`s f4gton, Months Hospital: 1 Inpatient 2 ER/Outpatient 3 DOA 28a. Date of injury (Month, Day Year) 28b. Time of injury 4b. City, Town, or Location of Death Bethesda.. 17; Father's Name (First,:Middle; Last) Albert Harvey Weaver',, Jr. Hours 10c. City, Town or Location Fart Lauderdale 13. Was Decedent of Hispanic Origin? (Specify Yes or No= 11 Yes, specify Cuban, Mexican, Puerto Rican, etc.) 1 Yes 2.R No Specify: 16a. Decedent's Usual Occupation (Gfve:kfnd of Work done of working life Q'NOT:0se .re _tireii) Inv _t or Ob. Place of Disposition (Name of Date. cemetery,, crematory or other place) nal Journey Crematorli 12/1/2010 2 Narne:a Address f Facility. Go ing r Home: C r�mation Servic P:O.. x 784 ;B 00957 ,everl :L.. Hec.ro'tte :P.A. C arksvi death. Do not enter the 'rode of dying, such as cardiac or respiratory arrest, 23c. If, yes, outcome of pregnancy f.:LJ Live Birth 2.L1 Fetal death 4' ❑.Pregnant at time of death:. 9 0 Unknown. 3 Ectopic pregnancy 5 Other (specify) Part 11. Other significant conditions contributing to1d rn eath butnot resulting the underlying cause given in Part of Iniury 'At`home farm,street,: building, etc (Sp 2. Date :of Death Usual Residence of Decedent 10g. Citizen' of What Country? United States 14, Race American:lndian, 31ack, White, etc. Specify: White 18. Mother's Name (First, Middle, Maiden Surname) :Cecilia Tereasa Kenly 19b, Mailing Address (Street: and Number:or Rural Route Number, City or Town, .State, Zip Code) 9500 Pa •e Avenue Bethesda :Ma land 20814 20c. Location City or Town, State Woodbine, land 21. Sign M 23a..Part'' Enter:the disease, or complications that caused the 'shock, orheart.failurer':List only one. cause on each line. lnimediate Cause (Final. d,sease or condition a. Adenoc l n• l�_ re'sulting:In death) th) Due to (dr as eq a consuence`of): Sequentially list conditions, If any, leading. to immediate Ouse: EnterUnderlying Cause(DiSease or injury that initiated events resulting: in death) Last Due to Due to (or as a consequence of): Approximate Inteivel Between. Onset and Death 29c,:Lic:ense nurtmti'er H45839 29d. Date signed (Month, Day Year) Noveii> ber '.26 2010 ape.an. ddress of person who completed cause of death (Item 23a) (Type, :t?rint) Gary Ra.ffei 5:41 Wi eda 203C Bethesda 31 pate flleil(6:imth,pa Yl]li610 32 (icgiStraygnatcr ors •'u 23d. Date of delivery: Month Day 23e. Did tobacco use contribute to the'causeof death? :1 ❑:'.Yes '25t No.. 3 Probably 4 ❑Unknown 24.13. Were autopsy:findings available prior to completion of cause of death? 1 ❑Yes 2 ❑No 25. Place'of.b.eeth (Check only one): Other: 4 Nursin. Hom 3 e 5 Residence 6 Other S•eci 28d. Descr'iliehow injury occurred 281 Location (Street and Number or Rural Route Number. City or Town; State) 29a. Certifier iJ Certifying Physician: To the best of my knowledge, death occured atthe'time, date and p(ave, and due tothe cause(s).and manner as stated: (Check 2 Medical Exam,ner.:On the basis of examination and /or investigation, in my opinion, death occurred at the tirne, date And place;;and, due to the cause(s) and manner stated: 'only ,qne) 3. Certifying. Nurse Practtoner: To.t. best :of m knowledge,.death occurred at the time, date and place, and due to the cause(s) and manner as stated. 29b: Signet.' '•'title of cetttfler; 1 M HMH 17 Rev 7 /2009 1 HEREBY CERTIFY THAT THIS:DOCUM IS ORIGINAL A TRUE COPY;OF.A REC.ORDON FILE IN, THE DIVISION OF VITAL`RECORDS. STATE REGIS 'tRAR` DO NOT:ACCEPT UNLESS ON SECURITY PAPER WITH SEAL OF VITAL RECORDSGLEARLY EMBOSSED.: For State Registrar amend STATE. ;OF MARYLAND Department of :H:ealth a:nd Mental Hygiene Divi of Vital: R Pe e se Ty Re or Print in BI k r delible'Ink. Ensure. All Copies Are Legible. l a -f G91182011 I arytand epar-tment5 Health and Mental Hygiend 0 I 0 Certificate of Death Reg. N: 007'31 l g a) t pp e I`�yiri,' Its f(� i �tltl rh 1 1'01 �G: �ih c w� P rid t 'f `ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE ,y' ;177