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Home My WebLink About966723STATE OF WYOMING COUNTY OF LINCOLN ss. Name Thomas Euvern Nelson AFFIDAVIT FOR COLLECTION AND DISTRIBUTION OF DECEDENT'S PERSONAL PROPERTY PURSUANT TO W.S. 2 -1 -201 1 Relationship Son u645 RECEIVED 9/11/2012 at 9:11 AM RECEIVING 966723 BOOK: 793 PAGE: 645 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY I, Thomas Euvern Nelson, being first duly sworn, on oath depose and state that I am making this affidavit pursuant to W.S. 2 -1 -201, on behalf of myself as sole distributee, as hereinafter set forth, and that I make the following statements in connection therewith: 1. That Corine Nelson became deceased on June 7, 2010, in Freedom, Lincoln County, State of Wyoming, and was a resident of Freedom, Wyoming, at the time of her death; that Archie Nelson aka Archie Demar Nelson, became deceased on June 4, 2005, in Afton, Lincoln County, Wyoming, and was a resident of Freedom, Wyoming, at the time of his death; that said decedents died testate; that I am the son of Corine Nelson and Archie Nelson; that I am the sole and only party entitled to the estate of the decedents in accordance with the laws of the State of Wyoming. 2. That the value of the entire estate of said decedent, wherever located, does not exceed $150,000.00. 3. That more than thirty (30) days have elapsed since the dates of death of the decedents. 4. That no application for the appointment of a personal representative of said decedents is pending or has been granted in any jurisdiction. 5. That the following named distributee is the sole and only party entitled to the estate of the decedents; that there are no other distributees of the decedents having a right to succeed to any of the property of the decedents under probate proceedings; and that therefore the following named claiming distributee is entitled to payment or delivery of all of decedents' property: 2012. 6. That among the assets owned by said decedents were the following vehicles: 1981 Trailer 1965 Dodge Truck 1999 Ford Pickup 1990 Trailer 1979 Ford Pickup 1974 Ford Truck 2004 Trailer 1969 International Truck That any and all interest of the decedents in the above listed vehicles should now be distributed to the undersigned. 7. That attached hereto and incorporated herein by this reference are a certified copies of the death certificates for the decedents Archie Nelson aka Archie Demar Nelson and Corine Nelson, respectively. 8. That the original of this affidavit is being filed of record in the office of the County Clerk of Lincoln County, Wyoming, in compliance with W.S. 2- 1- 201(c), as amended. EXECUTED as of the 10th day of September, 2012. Subscribed and sworn to before me by Thomas Euvern Nelson, this 10th day of September, Witness my hand and official seal. GERALD L GOULDING NOTARY PUBLIC County of State of Lincoln Wyoming My Commission Expires May 2, 2015 My commission expires: May 2, 2015. 2 Wyoming Title Number 12- 0227721 Wyoming Title Number 12- 0227720 Idaho Title Number 055010617 Idaho Title Number A91511302 Idaho Title Number 035003576 Idaho Title Number A025009298 Idaho Title Number 045012932 Idaho Title Number A045015812 0064 "WWI &1 Thomas Euvern Nelson NOTARY PUBLIC !/(i DECEDENTS LEGAL NAME (include AKA's if any) (First, 9210410. Last) 2 SEX 2(40s7 STATE OF WYOMI DATE OF DEATH (Mo/Day/Y0(Spen Month) ARCHIE DEM.AR NELSON. MALE J:UNE 4, 2005 4. SOCIAL SECURITY 1411M900 50. AGE Last 9616447.' 5b. UNDER 1 YEAR 50. UND R 1' DAY 6. DATE OF BIRTbil(Mo/DayNr) (Years) 78 Months Days Flours N"'" MAY 16 1927 70. 91(409 OF DEATH (ChM/ orlbi one) IF DEATHpCCURRED INA HOSPITAL: W DEATHOCCURRED'SCMEYAHERE (7/7196 THAN AMA/SPIT/LI: ninpallerit 0 Ent Outpatient gg 206 1 0 HospldifiFeifility 0 60r0(79 Horaa 1 Long Ten Caria.Pedifib, 0,Dacedect0 Honid ..ii Other( peifily) 7b. FACILITY NAME (If nifi institutlo, give street and number) 70, CilitTOWN:OR LOCATIONOF CEATW RS. COUNTY OF DEATH STAR VALLEY MEDICAL CENTER .AFT,O LINCOLN a. BIRTHPLACE (Soy end mete orilamar 0.0,112) i s, 92491541 si),,,s et map 9FDT.AIN "':.PV!1'..T.,INR.BaoUsa la e, ewe name p0100-ID Ilret,ruerriege) FREEDOM, IDAHO li 14 ..d i•iii ',II Mi'l i ff' m 'IMM 4 'F' '‘C:1 #.t k .""Is ..i i i i. CORINE PUTNAM 11 EVER IN U.S. FORSTS? WYOMING LINCOLN L. ,.'1; AnmED 740 HIGHWAY 239- 83120 13. FATHERS NAME (First. Middle. 1451) 14. MOTHERS NAME PRIOR TO FIRST MARRIAGE (FMASAIddle. Last) THOMAS- JOHN TRONA NELSON /1.10: GENE ASHMENT 15AANFORMANTS NAME 15b. TO DECEDENT 16s. MAILING ADD/166ESStreMILM(INUmbei.CiaA S(ate, Zipiooda) CORINE. P NELSON SPOUSE GENERALDELVERY..- FREEDOM, WYOMING 83120 16. METHOD OF DISPOSITION' TM. PLACE OF DISPOSITION (Ndauxof 17b. LOCATION C)TY, OR TOWN 9210 53809 IR Burial 0 DonatiOn 0 R moval from Wyoming 0 0,7791109 :13 Entoritithent 0 Other FREE DQM ..PEM4TERY F.4EEDOM, WYOMING 16a. SIGNATURE OF U IS ENSEE 16b. LICENSE No 190 98149 09 FACILITY i'' i I9b ADDRESS OF FACILITY. i tor person i EM -416 SCHWAB MORTOARY,‘, 44 EAST FOURTH AVE., AFTON 20 ACTUAL RESUMED TIMEOF DEATH 21. DATE PRONOUNCED DEAD 0.1001/6/70 22. test PpONCIUNCO DEAD 23. WAS CORONER CONTACTED? 1442 JUNE .4, 2005. 442 CAUSE OF-DEATH 24, PART 1 Enter the chain ol events diseases. Mamas or complications Mal throaty caused the death DO NOT Wet terminal aeinis 0005 05 cardiac Approximate interval: arrest. respiratory arrest, 01 00011140/61 fibrillation without showing ths etiology. DO NOT ABBREVIATE. Entef only one cause on a 194. AddAdditional lines Onset to death IMMED(ATE'CAUSk (Final Nemec iii, ..firjal4C14) DCC-AeLl.. cr.11‘ condition Fesulling sideath) DUE TO (or bs condaquend di ...1 Sequentially list conditions. II Any. Enter the UNDERLYING CAUSE b. ialle2 5 Feeding lo the cause limed on line a. (disease or inbuy that Inaled the PART 11. Enter other significant conditions contribuli to death but not resultinq16 the underlying cause Ovan)nyart I. 25. WAS AN AUTOPSY. PERFORMED? i \le-I A q ent-Lov 6 -rtA i v O YES 8.1 NO 26, WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? 27. DID TOBACCO USE CONTRIBUTE TO DEATH7 -0 YES 0 NO 10 YES ria NO l:0 PFS715AELY 0 UNKNOWN 29.9 FEMALE AGED 1,54 291-81/166(19 ER OF DEATH 014nt pregnant within 905/ 7031 0 Not pregnant, but Pregnant 43 ATys to I ye on(ore doo,h ii:i Retest C3 nornoceie 0 Pregnant at time ol death 1:3 Unknown il pregnant within the post year 0 eecitlent 0 Pending inVeatigeeon 0 Nol pregnant, but pregnant within 42 days of death 0 Suicide 0 Could n0150 determined 30. 0871 09 INJURY (Md(Day/Yr) 31. TIMEOF INJURY 37. PLAGE OF INJURY Bikeeenre hole., conslaifition.ifite, loreS1 eifi 33. INJURY AT WORK? O YES 0 90 34. LOCATION OF INJURY (Street end number. City or Town. Stale) 35. IF TRANSPORTATION ACCIDENT, SPECIFY: 0 Driver Operator 0 Pedestrian 36. .DESCRIBE HOW INJURY OCCURRED, ANDIATRANSPORTAT(QN INJURy, THE TYPE(S) OF VEHICLE(SMNVOLVED (A/demob/a, pic/(up. moterzycleiATV, bicycle. etc.) 370. CERTIFIER (09006 009 one) Ila PHYSICIAN-To the best of.my knowledge, death occurred at the time. date and.place. end. due to the causelM manner slata(1. 0 CORONE- On the basis ol exerhineflon, andiocinvesdiafiorxiin my miff., dame calconet;iM me. daN i2d Wadi/ anctilue Mike c.a900(1)) and Manneksteled. Signature of Cedilla, aL/ 1k2. 1.7: 37b. DATE CERTIFIED (90/20915,) 370. NAME, TITLE AND ADDRESS OF CERTIFIER (T)1po or pnnl) a.. D. P ERKE S:: ND .110. 1 HOSPITAL LANE AFTONy WYOMING 83110. 6 7-‘1 380.REGISTRAITS SI )15 T E 382 DATE 90ce,02 BY REGISTRAR (Me/Day/Yr) ,I f fira il. riP DEPARTMENT OF HEALTH •.<'Z..^;' This is a true and exact reproduction of the document on file in the office of Vital JUN 1 0 2005 p/114,it 4 DATE ISSUED: ,,,,,,,,'N-,,i e i,' %y■ This copy is not valid unless prepared on paper with an engraved border displaying the date, seal and signature of the Deputy State Registrar. Umii(21.1M rns)&ik LOCAL FILE NUMBER Records Services, Cheyenne, Wyoming. MIRSSIE§I STATE OF WYOMING DEPARTMENT OF HEALTH CERTIFICATE OF DEATH STATE FILE NUMBER Lucinda McCaffrey Deputy State Registrar kAL. .0,7772 4 1 1 10AP CERTIFICATI ;Pi itatidiMagni !•100111 Fe 923611 i ,I f fira il. riP DEPARTMENT OF HEALTH •.<'Z..^;' This is a true and exact reproduction of the document on file in the office of Vital JUN 1 0 2005 p/114,it 4 DATE ISSUED: ,,,,,,,,'N-,,i e i,' %y■ This copy is not valid unless prepared on paper with an engraved border displaying the date, seal and signature of the Deputy State Registrar. Umii(21.1M rns)&ik LOCAL FILE NUMBER Records Services, Cheyenne, Wyoming. MIRSSIE§I STATE OF WYOMING DEPARTMENT OF HEALTH CERTIFICATE OF DEATH STATE FILE NUMBER Lucinda McCaffrey Deputy State Registrar kAL. .0,7772 4 1 1 10AP CERTIFICATI ;Pi itatidiMagni !•100111 Fe 923611 STATE OF WYOMING DEPARTMENT OF HEALTH CERTIFICATE OF. DEATH 0 0; 4 p Decedent: State File Number: 2010 001646 :Name: Corine Nelson Gender: Female Social Security Number: Date of Birth: February 14, 1935 Age at the Time of Death: 75 years Date Arid Place of Death: Date of Death: June 07, 2010 County of Death: Lincoln City of Death: Freedom Location: 160 Nelson Ln. Additional Decedent Mace of Birth: Auburn, Wyoming Residence: Freedom Wyoming Marital Status: Widowed Armed Forces: No Name of Father: Euvern Frank Putnam, Name of Mother: Ruth Alice Searight Informant: Tom Nelson Relationship: Son Disposition: Method of Disposition: Burial 4 Place of Disposition: Freedom Cemetery, Freedom, Wyoming Funeral Home or Facility: Facility: Schwab Mortuary, Afton, Wyoming Cause; of Death: The immediate cause is listed on the first line followed by any underlying causes. Interval: (a) Congestive Heart Failure Minutes Other Significant Conditions: Manner of Death: Certifier: Type: Name: Address:‘` Date Filed: Natural Death Coroner Michael Richins, Coroner 274 N St, Box 57, Grover Wyoming 83122 June 09, 2010 This is a true certification of the document on file in the office of Vital Statistics Services, Cheyenne, Wyoming. DATE ISSUED: Wednesday, July 07,, 2910 z i This copy is not valid urdess,prepared on paper with an engrayed;bordcr Time of Death: 02:00 (Actual) a r v Gladys K. Breeden Deputy State Registrar In CERTIFICATION OF VITAL RECORD 11, }Is