HomeMy WebLinkAbout966413STATE OF WYOMING
SS.
COUNTY OF LINCOLN
dated April 26, 2008, is attached hereto.
hereby state:
AFFIDAVIT OF DISTRIBUTION
PURSUANT TO WYOMING STATUTES 2 -1 -201
FOR
THE ESTATE OF PHILLIP R. JORGENSEN
RECEIVED 8/24/2012 at 12:47 PM
RECEIVING 966413
BOOK: 792 PAGE: 375
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
COMES NOW Eva K. Jorgensen, after being sworn and under oath, hereby stating
pursuant to Wyoming Statutes 2 -1 -201, which authorizes Affidavits of Distribution, as follows:
1. That Phillip R. Jorgensen, a resident of Star Valley Ranch, Wyoming, died on
June 30, 2011. An official copy of the Certificate of Death of Phillip R. Jorgensen is attached
hereto.
2. That Phillip R. Jorgensen died testate. A copy of his Last Will and Testament,
3. That the Last Will and Testament of Phillip R. Jorgensen complies with the
requirements of Wyoming Statutes 2 -6 -114 and is therefore, a self proving will.
4. That the Last Will and Testament of Phillip R. Jorgensen names Eva K.
Jorgensen, Trustee, or her successors in trust, under the Phillip R. Eva K. Jorgensen Family
Trust dated April 26, 2008, and any amendments thereto, as the beneficiary of his estate.
5. That, in accordance with the requirement of Wyoming Statutes 2- 1- 201(a), I
AFFIDAVIT OF DISTRIBUTION
PURSUANT TO WYOMING STATUTES 2 -1 -201
FOR
THE ESTATE OF PHILLIP R. JORGENSEN
PAGE 1 OF 3
0037
a. That the value of the entire estate of Phillip R. Jorgensen, wherever
located, less liens and encumbrances, does not exceed Two Hundred Thousand Dollars
($200,000.00).
b. That Thirty (30) days have elapsed since the death of Phillip R. Jorgensen.
c. That no application for appointment of a Personal Representative is
pending or has been granted in any jurisdiction.
d. That pursuant to the Last Will and Testament of Phillip R. Jorgensen, I, as
the sole Trustee of the Phillip R. Eva K. Jorgensen Family Trust dated April 26, 2008,
and any amendments thereto, am the beneficiary of his Estate. There are no other
persons or entities having a right to said assets under probate proceedings.
6. That as beneficiary of the Estate of Phillip R. Jorgensen, I hereby request that the
following asset belonging to Phillip R. Jorgensen be transferred to "Eva K. Jorgensen, Trustee of
the Phillip R. Eva K. Jorgensen Family Trust dated April 26, 2008, and any amendments
thereto a 2008 PJ TR Flatbed VIN No. 3CVCH202882117585, currently titled in the name of
"Phillip Jorgensen The original Certificate of Title is enclosed with this Affidavit.
DATED this 23 rei day of August, 2012.
AFFIDAVIT OF DISTRIBUTION
PURSUANT TO WYOMING STATUTES 2 -1 -201
FOR
THE ESTATE OF PHILLIP R. JORGENSEN
PAGE 2 OF 3
EVA K. JOR NS N
0037
ON THIS, the 23rd day of August, 2012, Eva K. Jorgensen, affiant herein, appeared
before me, and being duly sworn under oath, affirmed that the facts stated in this Affidavit of
Distribution are, to the best of her knowledge, information, and belief, true and complete.
WITNESS my hand and official seal.
M KEVIN VOYLES NOTARY PUBLIC
County of
Lincoln
State of
Wyoming
My Commission Expires: July 16, 2015
My Commission expires: oi1 1,.i J,r
AFFIDAVIT OF DISTRIBUTION
PURSUANT TO WYOMING STATUTES 2 -1 -201
FOR
THE ESTATE OF PHILLIP R. JORGENSEN
PAGE 3 OF 3
0037'
FATHER NAME
TED JORGENSEN
MOTHER MAIDEN NAME
ENA.LOU NEU:ENSGHWANDER
METHOD OF DISPOSITION FUNERAL SERVICE LICENSEE,.
REMOVAL FROM STATE 1 DAVID N -MATTHE.W
NAMEAND ADDRESS OF FUNERAL FACILITY
MATTHEWS MORTUARY, I.NC.,iMON;TP:ELIER, IDAHO
DATE OF DEATH TIME OF DEATH .CITY.TOWN OR LOCATION OF DEATH
JUNE 30, 2011 11;40 A.M.: M:ONTPEL`LER, IDAHO
CAUSE OF DEATH (underlying cause last)
CEREBRAL VASCULAR ACCIDENT
DUE TO for as a consequence of);
b. STAPH- AUREUS SEPSLS 1 WEEK
DUE TO (or .as a consequence of):
c.
DUE TO (or :asa consequence of)::
d.
OTHER SIGNIFICANT CONDITIONSCONTRIBUTING TO'pEATH but esultiny in the:undedying cause;given above
END STAGE RENAL DISEASE; PULMONARY FLB :R
MANNER OF DEATH FLAME OF CERT)HER
NATURAL JACK 0. CLARK,M.D.
C.ORONERSUBSEQUENT _CERTIFICATION IF NECESSARY
COUNTY OF DEATH
BEAR LAKE
.Approxiinate'Interval Between
Ansel and Death
1. :WEEK
WAS AN AUTOPSY
PERFORMED?
DECEDENT LEGAL NAME
PHILLIP RAY JORGENSEN
SEX
MALE
BIRTHPLACE
AFTON, WYOMI,NG
MARITAL STATUS. AT TIME OF DEATH
MARRIED
DATE OF INJURY
LOCATION WHERE INJURY OCCURRED
DESCRIPTION OF HOW INJURY OCCURRED
SOCIAL SECURITY NUMBER
STATE' E IDAHO
IDAHO DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF 'VITAL RECORDS AND HEALTH STATISTICS
CERTIFICATE OF DEATH
TIME OF INJURY
MAME OF SURVMNG.SPOUSE (If ofa, maiden name)
A K MAH
EV N
PLACE OF INJURY
This is a true and correct reproduction of the dootlment officially registered and placed
on file with the IDAHO`BUREAU'OF VITAL.RECOROS ANfS HEALTH STAT1:STIOS.;-
DATE OF BIRTH
•JULY 116, 1949:
PLACE.OF RESIDENCE
STAR VALLEY RANCH W:YOMIN.G
BIRTHPLACE
'WYOMING
91RFNPLACE."
WYOMING
WAS DECEDENT EVER IN
U.S. ARMED FORCES?
NO
DATE ISSUED:
This copy not valid unless prepared on engraved border
displaying state seal and.Signature of -The Registrar
PBNWIM'L Ole
LAST WILL AND TESTAMENT
OF
PHILLIP R. JORGENSEN
003'°9
I, PHILLIP R. JORGENSEN, of Star Valley Ranch, County of Lincoln, State of
Wyoming, being of sound and disposing mind and memory and being in reasonably good health,
but mindful of the uncertainties of life, hereby make, publish and declare this to be my Last Will
and Testament, hereby revoking all previous wills and codicils heretofore made by me.
FIRST: I direct that all my just debts and obligations, including my funeral expenses,
the expenses of my last illness, and the expenses of the administration of my estate, be paid by
my Executor, hereinafter named, as soon as is reasonably possible.
SECOND: If permitted under the laws of Wyoming, I give any and all of my tangible
personal property (including but not limited to, jewelry, clothing, household furniture,
furnishings and fixtures, chinaware, silver, photographs, works of art, books, boats, automobiles,
all artifacts relating to my hobbies, and all other articles of household or personal use) that I list
on a written, signed, and dated memorandum that may be left by me, in accordance the
distributions specified therein. Should I leave multiple written memorandums which conflict as
to the disposition of any item of my tangible personal property, then that memorandum which is
dated last shall control as to any items which may be in conflict.
THIRD: All of the remainder of my estate, be it real, personal or mixed property,
LAST WILL AND TESTAMENT
OF
PHILLIP R. JORGENSEN
PAGE 1 OF 6
distribute the Trust principal and accumulated income to said heir.
LAST WILL AND TESTAMENT
OF
PHILLIP R. JORGENSEN
PAGE 2 OF 6
00380
wherever situate, I give, devise, and bequeath to EVA K. JORGENSEN, TRUSTEE, or her
successors in trust, under the PHILLIP R. EVA K. JORGENSEN FAMILY TRUST dated
April 26, 2008, and any amendment(s) thereto. If said Trust is no longer in effect at my death, I
give all of my property to my wife, EVA K. JORGENSEN, and if she is no longer living, I give
all of my property to my children, LISA K. CUNLIFFE, JOSEPH M. CUNLIFFE, AIMEE K.
STEIL, JOHN S. JORGENSEN, AND TED R. JORGENSEN, per stripes, provided, however,
that, if at the time of my death, any heir has not yet achieved the age of thirty (30) years, I devise
and bequeath that portion of my estate given, devised, and bequeathed to such heir to LISA K.
CUNLIFFE, JOSEPH M. CUNLIFFE, AIMEE K. STEIL, JOHN S. JORGENSEN, AND TED
R. JORGENSEN, or the survivor(s) of them, as Trustee(s), to be held in Trust upon the following
terms and conditions:
a. The Trustee(s) shall pay from the income or principal of the Trust assets such
sum or sums of income or principal as the Trustee(s), in the Trustee(s)' sole discretion,
deem necessary or proper to provide for said heir's suitable care, support, education, and
maintenance, adding the unused income, if any, to the Trust principal at the end of the
year.
b. After said heir attains the age of thirty (30) years, the Trustee(s) shall
c. The Trustee(s) are vested, in addition to those powers now or hereafter
conferred by law, with all the rights, powers and discretion with respect to each item of
property in the Trust estate, real and personal, which an absolute owner of such property
0038'
would have, and all powers granted to trustees by the Wyoming Uniform Trust Code, the
provisions of which are incorporated herein by reference.
d. All heirs who are the beneficiaries of the Trust created herein, are restrained
from and shall be without authority or power to sell, assign, transfer, pledge, mortgage,
hypothecate, alienate, anticipate, or in any manner encumber, impair or otherwise affect
her beneficial rights, interests or claims in or to income or principal of the Trust created
hereunder during the term thereof, nor shall the right, title, interest or estate of the
beneficiary be subject or liable to the rights or claims of creditors or to any process of law
whatsoever.
If my wife and/or above specified heirs do not survive me, I give, devise, and bequeath
said property to my heirs at law according to the laws of descent and distribution of the State of
Wyoming.
FOURTH: I hereby nominate, constitute and appoint my wife, EVA K. JORGENSEN,
as Executor of this my Last Will and Testament and I direct that the said Executor shall not be
required to give any bond or other surety in connection with qualifying or acting in this capacity.
In the event that she fails to survive me, or if she is unable or unwilling to serve, then I nominate,
constitute and appoint :LISA K. CUNLIFFE as Executor of this my Last Will and Testament and
I direct that the said Executor shall not be required to give any bond or other surety in connection
with qualifying or acting in this capacity.
FIFTH: I hereby give my Executor appointed herein, in addition to and not in limitation
LAST WILL AND TESTAMENT
OF
PHILLIP R. JORGENSEN
PAGE 3 OF 6
of their statutory and common law powers, the following powers:
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a. To settle and compound any claims either in favor of or against my estate, to
execute all proper and necessary conveyances, and to give full receipts and discharges;
b. To sell, convey, exchange, transfer, assign, mortgage, pledge, invest, or
reinvest the whole or any portion of my real or personal estate; and
c. In general, to do and to perform all acts and things whatsoever the
Executor could do and perform if he or she were the absolute owner thereof, and no
Executor shall be liable for the acts, omissions, or defaults of any agent appointed with
due care, no Executor shall be liable for the failure to contest the accounts of any
preceding Executor, and no Executor shall be liable for the failure to redress a breach of
trust.
IN WITNESS WHEREOF, I, PHILLIP R. JORGENSEN, have hereunto set my hand
to this my Last Will and Testament, typewritten on six (6) pages, including the attestation clause
the signatures of witnesses, and the Notary's certificate, this 264-day of April, 2008.
LAST WILL AND TESTAMENT
OF
PHILLIP R. JORGENSEN
PAGE 4 OF 6
I, PHILLIP R. JORGENSEN, the Testator, sign my name to this instrument this 26A
day of April, 2008, and being first duly sworn, do hereby declare to the undersigned authority
that I sign and execute this instrument as my Last Will and Testament; that I sign it willingly;
that I execute it as my free and voluntary act for the purposes therein expressed; and that I am an
adult person, of sound mind, and under no constraint or undue influence.
We, egKisriii 4, JAR VI S and Pi4TX (G6 4 4. REFS
the witnesses, sign our names to this instrument, being first duly sworn, and do hereby declare to
the undersigned authority that the Testator signed and executed this instrument as his Last Will
and Testament; that he signed it willingly; that he executed it as his free and voluntary act for the
purposes therein expressed; that each of us, in the presence and hearing of the Testator, hereby
sign this as witnesses to the Testator's signature; and that, to the best of our knowledge, the
Testator is an adult person, of sound mind, and under no constraint or undue influence.
.Inn.t/.yt� 1►1�..� 0 G-D N UTAH
WITNESS RESIDING AT
WITNESS RESIDING AT
LAST WILL AND TESTAMENT
OF
PHILLIP R. JORGENSEN
PAGE 5 OF 6
oe- &nr (kT±
STATE OF 140 /0 ri/MIG
COUNTY OF ZINCOLA/
SUBSCRIBED AND SWORN TO before me by PHILLIP R. JORGENSEN, the
Testator, and by Ckg/57 4 fi kf/lS and /1%i¢77 /c /A 4. /Q '5
witnesses, this 26- day of April, 2008.
WITNESS my hand and official seal.
M. KEVIN VOYLES NOTARY PUBLIC
COUNTY OF -it.± STATE OF
LINCOLN "�I! WYOMING
MY COMMISSION EXPIRES JULY 16, 2011
My Commission expires:
SS.
LAST WILL AND TESTAMENT
OF
PHILLIP R. JORGENSEN
PAGE 6 OF 6
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