HomeMy WebLinkAbout968124BANK'AWEST
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AFFIDAVIT UNDER PENALTY OF PERJURY FOR RELEASE OF ACCOUNT
OR PERSONAL PROPERTY WITHOUT COURT ADMINISTRATION
WYOMING STATUES SECTION 2 -1 -201 ET SEQ.
(FOR ESTATES WITH A TOTAL VALUE OF $200,000 OR LESS)
NOTICE TO BANK: MUST BE FILED WITH COUNTY CLERK AND BANK MUST RECEIVE A CERTIFIED COPY
PRIOR TO ANY DISTRIBUTION OF ASSETS.
I/We [Enter name(s)] 31: e'Y ,(�+l /Y) (individually
and jointly "Affiant whose address(es) is /are: (Attach additional sheets as needed)
94 5 )e) Ma 0 c ;4/ K* Z4
declare to Bank of the West "Bank that the following is true and correct:
1. (Name of Deceased) it 004 1-.66 Rcc f r (the "decedent died in the City of
46t164-09-f) County of c` A.± 1� State of C,.,h(,11
on (Date) 63/ b J of 9\
2. At least thirty (30) days have elapsed since the death of the decedent, as shown in a certified copy of the decedent's death
certificate attached to this affidavit.
3. No application for appointment of a personal representative is pending or has been granted in any jurisdiction.
4. The current value of the decedent's entire estate, wherever located, less liens and encumbrances, does not exceed two hundred
thousand dollars ($200,000).
5. The claiming distributee(s) are entitled to payment or delivery of the property by virtue of the following facts concerning the
distributee's relationship to the decedent: Distributee(s) are: [Check appropriate bor(es)]: Parent(s); Spouse;Child(ren);
Grandchild(ren); Sibling(s); Child(ren) of Sibling(s); Aunt(s)/Uncle(s); Heir(s) under will; Heir(s) at law;
Trustee of trust taking under a pour -over will; Other Describe:
There are no other distributees of the decedent having a right to succeed to the property under probate proceedings.
6. At the time of the death of the decedent, the decedent was the owner of certain personal property held by Bank of the West, which
personal property is described as follows:
(a) Funds on deposit in the aggregate sum of Dollars
in the following accounts:
Branch Name City /State Account No. Amount
(b) Personal property situated in safe deposit box or vault no. or held in safekeeping at this branch; (Enter
Branch Name and State) o 44 O f f E e 1 u)y)olyitag--
(c) The decedent's interest in: (Describe)
RECEIVED 11/26/2012 at 12:17 PM
RECEIVING 968124
BOOK: 798 PAGE: 759
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
(continued)
030- 05180(Rev, 07/11)
State of
7. The affiant is entitled to payment or delivery of the described property, has the relationship described below and requests that the
described property be paid, delivered or transferred to affiant(s) directed as follows:
Name and Address
1)
2)
3)
4)
Relationship to Decedent
Proportion Due Each Distributee
8. Affiant is the successor to the decedent's interest in the described property or is authorized to act on behalf of the successor of the
decedent with respect to the decedent's interest in the described property and no other person has a superior right to the interest of
the decedent in the described property.
9. If there is more than one affiant, all statements in this Affidavit are made individually and jointly.
10. In consideration for Bank's honoring this Affidavit, Affiant(s) agree(s) that Bank cannot be held liable for giving
Affiant(s) the money and /or property described in paragraph 6 and agree(s) to indemnify Bank and bold Bank harmless
against all liability, loss, costs, damages or expenses, including attorneys fees, which Bank may incur by reason of its
honoring this Affidavit. A receipt for the payment by each of the distributees shall constitute a valid and sufficient release and
discharge of Bank of the payment made.
11. Affiant represents and warrants that Affiant has been advised to consult with legal counsel prior to executing this
Affidavit and that Affiant has had the opportunity to consult with legal counsel and has obtained such legal guidance as
Affiant has deemed appropriate prior to executing this Affidavit.
12. Each affiant affirms or declares under penalty of perjury under the laws of the State of Wyoming that the foregoing is true and
correct.
This Affidavit is executed on /cQ (a 20 in the City of j OftfYf eT f'
ii S EX oCUTED BY ALL DISTRIBUTEES.
Affidavit Small Estt el!xgpt'ng
Page 2 of 2
Signature:
Si hire
STATE OF r Z..
COUNTY OF
On V"V
appeared personally
known to ne (or proved me on t ba s •f satisfactory evidence) to be the person(s) whose name(s)is/are subscribed to the within
instrument and acknowle• _ed to me that he she /they executed the same in his/her /their authorized capacity(ies), and by his/her /their
signature(s) on the instnunent the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Signature
20
Signature
Signature
WITNESS my hand and.offreiesea1
before tne, the undersigned, a Notary Public in and for said State, personally
(Seal)
JAMIE PAINTER NOTARY PUBLIC
COUNTY OF
LINCOLN
STATE OF
WYOMING
GG
My Commission Expires C) a0
-05130 (Rev. 07/11)
rr sf if v
CERTIFICATION OF VITAL RECORD
V.V4. V.
DECEDENT INFORMATION
Date of Death: Augtst 16, 2012
City of Death: Holladay
Age: 70
Place of Birth: Kemmerer, WyoMing
Armed Services:
Spouse's Name:
Industry/Business:
Residence:
Mother's Name:
Facility or Address:
INFORMANT INFORMATION
Name: Vivian- Rochford Retitigrtshl
Mailing Address: 612 dpal
DISPOSITION INFORMATION
Method of Disposition: Cremation
Place of Dispositibn:_ Ut#hfuriefat_DireCtpi:s 0-tdeati00 S5ith1ocdan ,'.Uidh
Date of DispoSition: Atst202Q12 'r-
FUNERAL HOME-INFORMATION:
Funeral Home: Crandall Funeral Home I
Address: PO Box 6, 105 East Street, Kamas, Utah 84036
Funeral Director: William W Ball,
MEDICAL CERTIFICATION
C4USE jr DEATH'.
Stage IV Prostate Cancer
Other significant conditions: Obstructive Kidney Failure, Senile Dementia
Tobacco Use: Probahlji,
Medical Examiner Contacted Yes AAutopsy Per9iiicJNc Mitanerigt: atural
'Yes
VIN:iian Denise Carlsdn:
Oil add Gas
Kemmerer, Wyoming
Nell Sloan
Holladay Healthcare
Medical Professidnal: Charles Steven:Fehled
ah 84093
k
Date Registered: August 20, 2012
Date Issued: November 21, 2012
CERTIFICATE OF DEATH
State StateEile I>1jnber
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This is an exact reproduction:di thkfActs_ registered inveiStalOffice-of Vital Statistics.
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Time of Death: 13:10
County of Deat Salt Lake
CAW otlitd_WarZ5 Aug ust20 1941
Teti Mle
Malifal=ltatn ..FWV1arried-
Usekr4Pciftoilv::: Communications
Eduatbn: High School or GED
Father's Name: Ira R Rdchford
Facility Type: Nursing Home/Assisted Living
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