HomeMy WebLinkAbout969478IN THE DISTRICT COURT OF THE THIRD JUDICIAL DISTRICT
IN AND FOR THE COUNTY OF LINCOLN, STATE OF WYOMING
IN THE MATTER OF DETERMINATION OF HEIRSHIP OF
ROLLO L. HANSEN, Deceased.
STATE OF WYOMING
ss.
COUNTY OF LINCOLN
I, Donald Hansen, being first duly sworn, on oath depose and state as follows:
1. That I am over the age of twenty -one (21) years.
2. That Rollo L. Hansen is my brother.
3. That my brother, Rollo L. Hansen died on December 18, 2012, in Kemmerer, Lincoln
County, Wyoming
4. That my brother, Rollo L. Hansen did not have a Will upon his death and accordingly
died intestate.
5. That the only heir of Rollo L. Hansen is myself, Donald Hansen.
6. That the value of the entire estate of Rollo L. Hansen, wherever located, does not
exceed two hundred thousand dollars ($200,000).
7. That thirty (30) days have elapsed since the date of the death of Rollo L. Hansen.
8. That no application for appointment of a personal representative is pending or has
been granted in any jurisdiction regarding Rollo L. Hansen.
9. That I am entitled to my share of the payment or delivery of the property of Rollo L.
Hansen and there are no other distributees of the decedent having a right to succeed
to the property under probate proceedings.
10. That the personal property owned by Rollo L. Hansen is as follows:
a. Union Death Benefit and any other proceeds
11. That if any other personal property is located that is not identified above, I am
entitled to that property.
Probate \Hansen \Affidavit of Distribution
AFFIDAVIT FOR DISTRIBUTION OF ESTATE
"951
Probate No.
RECEIVED 2/13/2013 at 3:41 PM
RECEIVING 969478
BOOK: 804 PAGE: 564
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Dated this I day of February, 2013.
STATE OF IDAHO
COUNTY OF Q a (1 (1 o c k
day of February, 2013 by Donald Hansen.
ss.
Probate Hansen \Affidavit of Distribution 2
DONALD HANSEN
DONALD HANSEN
.14Y
I, Donald Hansen being first duly sworn, states that I am the affiant noted above, that I have
read the same, know the contents thereof, and that the statements contained therein are true.
This Affidavit for Distribution of Estate was subscribed and sworn before me this 11
My Commission Expires: 'MS /2_0
CERTIFICATI
Place of Birth:
Residence
Marital Status:
Forces:
Name of Father:
Name of Mother:
Informant:
Other Significant
•Conditions:
Manner of Death;,
Certifier:
Type:
Name:
Address:
Date Filed:
Date and Place of Death:
Date of Death:
City of Death:
Location:
Additional Decedent tnforma
Disposition:
Method of Disposition: Cremation,:
Place of Disposition:
Funeral Home or Facility:
Facility:
Rollo L. Hansen
Male
May 12, 1922
tion:
Natural Death
December 18, 2012
Kemmerer
South Lincoln Nursing Center 711
Ogden, Utah
Kemmerer, Wyoming
Never Married
Yes
Quincy Lafeyette Hansen
Annie Florene Beard
Donald Hansen
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
UFD Cremation Center, South Jordan, Utah
Ball Family Chapel, Evanston, Wyoming
Cause of Death:
The immediate cause is listed on the first line followed by any underlying causes:
(a) Atrial Fibrilation
(b) Hypertension
Physician
Chad Seiler, M.D.
PO Box 390, Kemmerer, Wyoming, 83101
December 27, 2012
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming,
Thursday 03, 2013
DATE ISSUED:
r ,ff This copy, is not valid unless prepared on paper with an engraved border.
State File Number:
Social Security Number:
Age at the Time of Beath:
Relationship:
Brother
18:40 (Approximate)
d t rrcAS /*a:4,
ames McBride
Deputy State Registrar
131�Ji�YtJfJ riu a.l iiCMRE
FINANCING LTC UNIT
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VITAL RECORD