HomeMy WebLinkAbout969887STATE OF WYOMING
LLY_L.L
COUNTY OF
the Matter of he Estate of
Decedent
/7_1/10--J upon duly sworn, state on my oath on behalf of myself and
all of Zer distributees, that:
1. My maili ddress is:
/LAS
treet Address
f
C tate
Zip code
My Residence Address is:
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S reet Address'
if
City, State
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Zip code
2. The decedent's full name is:
AFFIDAVIT OF SMALL ESTATE
DISTRIBUTEES
a
IN THE DISTRICT COURT
JUDICIAL DISTRICT
NO
3. More than thi (30) days have elapsed since decedent's death. The date of the decedent's
death was L ,ti it t4 U v� Q I have attached a copy of the
death certificate ereto.
4. 1 am a distributee of the decedent's estate as defined in Wyoming's Statutes 2 -1 -301 (XIII).
All distributees of the decedent, including myself, are listed as follows:
RECEIVED 3/12/2013 at 10:06 AM
RECEIVING 969887
BOOK: 806 PAGE: 571
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Surviving Spouse:
elationship:
elationship:
elationship:
elationship:
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Address:
City:
state: DhL t/
Zip code:
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City: F
State: S-
Zip code: 2R V) C
DOB: (minors only)
Name:
Address:
Name:
Address:
City:
State:
Zip code:
DOB: (0
Name: A ,iv_
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State:
Zip code:
DOB: (minors only)
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ors only) ,f
Name:
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DOB: (minors only)
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5. That the value of the entire estate of the decedent, wherever located, less liens and
encumbrances, does not exceed One Hundred fifty Thousands Dollars ($150,000.00).
6. No application or petition for the appointment of a personal representative is pending or has
been granted in any jurisdiction.
7. The claiming distributes are entitled to payment or delivery of the property, and there are no
other distributes of the decedent having a right to succeed to the property under the probate
proceedings.
Under penalty of perjury, I /We declare that I /We have read the foregoing and the facts alleged
are true, to the best of my /our knowledge and belief.
Date: ql 1. Signature of Petitioner:
Print Name of Petitioner: clktiarci e_- lif CIL
Address: I r) 4-(( (p A L. r.. r`Q
City: {"n n
State: Ua i .(p Pa tV�
c
Zip code: 72,1 1 C)
Phone: "7) Og 3 jLJ
Zip code: g H o
Relationship to Decedent: C p r) Lt
State of Wyoming
County of ied/
The following instrument was acknowledged before me this /Cl day of rifbi t i6 t
Z.0- 1-0 l l'� ��r i 14- 110 .c. 1
2C-13,Al2.
(seal)
AMBER M. ROBERTSON NOTARY PUBLIC
County Of
Lincoln
State Of
Wyoming
Acknowledgement
My Commission Expires May 15, 2013
My commission Expires: k-(aLi in, 713
i i !i?, d1n
otary Pu lic
Printed Naive
c0 `d 3
Akiy2
Decedent: State File Number: 2018_000038
Name: Sally Barber Bruce
Gender: Female Social Security Number:
Date of Birth: September 07, 1948 Age at the Time of Death: 64 years
Date and Place of Death:
Date of Death: January 06, 2013 County of Death: Lincoln
City of Death: Afton
Location: 142 Allred Rd.
Additional Decedent Information:
Place of Birth: Afton, Wyoming
Residence: Afton, Wyoming
Marital Status: Married Edward Harry Bruce
Armed Forces: No
Name of Father: Walter Riches Barber
Name of Mother: Lorraine Wright Heap
Informant: Edward Harry Bruce Relationship: Husband
Disposition:
Method of Disposition: Burial
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.
(a) Respiratory failure
(b) Malignancy
Other Significant
Conditions:
Manner of Death: Natural Death Time of Death: 23:10 (Actual)
Certifier:
Type: Physician
Name: David L. Shrader, M.D.
Address: 110 Hospital Lane, PO Box 579, Afton, Wyoming, 83110
Date Filed: January 14, 2013
685359
This copy is not valid unless prepared on paper kith an engraved hordcr.
STATE OF WYOMING
DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
Interval:
This is a true certifiication�.°f the d cume t n tile in of�jjc�egp /1
Statistics Services, Cheydrir! W (ngnarcll U LU I i onnts I�/�yj.4{,
DATE ISSUED: James McBride
Deputy State Registrar
14
Am tl•anpank Note la,mpnilT wit/R. /4
istr: CERTIFICATI 1 VITAL RECORD
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