HomeMy WebLinkAbout971508STATE OF WYOMING
COUNTY OF LINCOLN
AFFIDAVIT FOR DISTRIBUTION
OF DECEDENT'S PERSONAL PROPERTY
PURSUANT TO W.S. 2 -1 -201
ss.
RECEIVED 6/17/2013 at 10:48 AM
RECEIVING 9 7 1508
BOOK: 813 PAGE: 771
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
I, JOAN MARTIN, 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 distributee, as hereinafter set forth, that I make the following
statements in connection therewith:
1. That ELMER M. MARTIN became deceased on September 18,
2010 in Idaho Falls, Bonneville County, State of Idaho, and was a resident
of Afton, Lincoln County, State of Wyoming, at the time of his death; that
said decedent died intestate; that said decedent left Joan Martin, as surviving
spouse; that the sole and only party entitled to the estate of said decedent is
the distributee hereinafter named; a copy of the Certificate of Death of
decedent is attached hereto as Exhibit "A
2. That the value of the entire estate of said decedent, wherever
located, does not exceed $200,000.00.
3. That more than thirty (30) days have elapsed since the date of
death of the decedent.
4. That no application for the appointment of a personal
representative of said decedent 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 decedent, that there are no other distributees of
the decedent having a right to succeed to any of the property of the decedent
under probate proceedings, and that therefore, the following named claiming
distributee is entitled to payment or delivery of all of the decedent's
property:
Name
Joan Martin
Relationship
Wife
6. That among the assets owned by said decedent is the following:
1980 S &H 4 -horse trailer, VIN804522
7. That an executed copy of this Affidavit is being presented to the
transfer agent for the above listed asset in compliance with W.S. 2 -1 -201.
Furthermore, pursuant to W.S. 2 -1 -201, the depository for any income or
interest in the above entitled asset is hereby directed to pay any deposit or
any funds in said account that were in the name of the decedent, together
with any interest and dividends thereon, payable to distributee listed here.
Affidavit for Distribution
Page 1 of 2
ty 4j 7 7 1
Name and Address
Joan Martin
347 Madison
P.O. Box 275
Afton, WY 83110
STATE OF WYOMING
ss.
COUNTY OF LINCOLN
CiRYSi t711%.'Y PUBLIC
ur nry ;t,>te of
iru; 1, t Wyoming
t
My omm on u(:::, t -0oruary 3, 2014
+rs.wv*vry o an^t Ws^ .r+iyPt""".P\s.:
My Commission Expires:
Date of Birth Social Security No.
03/01/1944
EXECUTED this J.j) day of June, 2013.
JO N MARTIN
SSN:
Address: 347 Madison, P.O. Box 275
Afton, WY 83110
SUBSCRIBED AND SWORN to before me, a Notarial Officer, by
JOAN MARTIN this day of June, 2013.
NOTARY PUBLIC
CERTIFICATION OF VITAL RECORD
Date Filed
MALE
BIRTHPLACE
SEPTEMBER 22
1 SACRAMENTO, CALIFORNIA
J MANNER OF DEATH
NATURAL
DATE OF INJURY
LOCATION WHERE INJURY OCCURRED
DESCRIPTION OF HOW INJURY OCCURRED
SOCIAL SECURITY NUMBER
TIME OF INJURY
DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF VITAL RECORDS AND HEALTH STATISTICS
NAME OF CERTIFIER
74 YEARS
MARITAL STATUS AT TIME OF DEATH NOME OF SURVIVING SPOUSE (If wife, maiden name)
MARRIED JOAN JOHNSON
FATHER NAME
RAYMON MONROE MARTIN
MOTHER MAIDEN NAME
MINNIE ERMA BROOKS
METHOD OF DISPOSITION FUNERAL SERVICE LICENSEE
REMOVAL FROM STATE JASON P. MECHAM
NAME AND ADDREpS OF FUNERAL FACILITY
NALDEE�'S FUNERAL HOME, SHELLEY, IDAHO
WALLACE C. BAKER, M.D.
PLACE OF RESIDENCE
AFTON, WYOMING
CORONER SUBSEQUENT CERTIFICATION IF NECESSARY
This is a true and correct reproduction of the document officially registered and placed
on file with the IDAHO- BUREAU OF VITAL RECORDS AND HEALTH STATISTICS.
7
SEPTEMBER 22, 2010
DATE ISSUED•
I
This copy is not valid unless prepared on engraved border JANE S. SMITH
displaying state seal and signature of the Registrar. STATE REGISTRAR
PLACE OF INJURY
State File No
BIRTHPLACE
CAL IFORNIA
BIRTHPLACE
CAL IFORNIA
TITLE
PHYSICIAN
2010 -07895
WAS DECEDENT EVER IN
U.S. ARMED FORCES?
NO
DATE OF DEATH TIME OF DEATH CITY,TOWN OR LOCATION OF DEATH COUNTY OF DEATH
SEPT. 18, 2010 12:30 P.M. IDAHO FALLS, IDAHO BONNEVILLE
CAUSE OF DEATH (underlying cause last) Approximate Interval Between
Onset and Death
a MYOCARDIAL INFARCTION 1 MINUTE
DUE TO (or as a consequence ot):
b ATHEROSCLEROSIS 20 YEARS
DUE TO (or as a consequence ot):
a
DUE TO (or as a consequence o1):
OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH but not resulting in the underlying cause given above WAS AN AUTOPSY
PERFORMED?
CEREBRAL VASCULAR ACCIDENT ENO
INJURY AT
WORK?