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When recorded mail to:
John G. Hampshire
PO Box 853
Thayne, WY 83127
AFFIDAVIT AND ACCEPTANCE OF TRUSTEESHIP
Comes now the undersigned Sandra S. Hampshire and Kyle J. Hampshire and being on oath first duly
deposes and says:
1. That I/ WE are citizens of the United States of legal age and capacity, and competent to make this
affidavit.
2. That I /WE was personally acquainted with the deceased, Dorothy Jean Hampshire listed in that
certain document as recorded on October 28, 1994 at Entry No. 792200 in Book 359 at Page 667 in the
office of the Lincoln County recorder, State of WY.
4. That the purpose of this affidavit is for Sandra S. Hampshire and Kyle J. Hampshire to accept the
Trusteeship of the Hampshire House Trust and hereby agree to act as Trustees of said Trust on all the
terms, provisions and conditions specified in said Trust.
5. That a certified death certificate of the deceased is hereby attached.
Legal description:
ALL OF LOT 14 OF THE STAR VALLEY RANCH PLAT 3, LINCOLN COUNTY, WYOMING, FILED MARCH 3, 1971 AS
INSTRUMENT NO. 428885 IN THE OFFICE OF THE LINCOLN COUNTY CLERK.
State of WY
County of Lincoln ss:
On June J 2013 personally appeared before me Sandra S. Hampshire and Kyle J. Hampshire the
signer(s) of the within instrument, who duly acknowledged to me that They executed the same.
Dyanna Parker Notary Public
County of State of
Lincoln Wyoming
My Commission Expires
Sandra S. Hampshire
le J. Hampsh'.
Notary P
Commis
60001
RECEIVED 6/18/2013 at 4:12 PM
RECEIVING 971540
BOOK: 814 PAGE: 1
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
Expires:,-(9
J1HtEEIEL
1 DECEDENT'S
NAME ffusp (Mode) (Lass)
D�'H' JEAN S U D O 21,1CN firrICN HAMPSHIRE
5. SOCIAL SECURITY NUMBER
2. SEX
Female
3. DATE Of DEATH Imonth, day. year) 1. TIME OF DEATH
September 22, 1995 I12:32am
8. BIRTHPLACE Icily and lorefgn
6a AGE last Birthday (years)
69
6b. UNDER I YEAR
Sc. UNDER 1 DAY
7. DATE OF BIRTH Imonth, day, year)
May 28, 1926
months
days
hours
minutes
stale of country)
Cadillac, Michigan s
106. FACILITY NAME lit not msotuuon
9 WAS DECEDENT EVER IN U.S.
ARMED
RMED FOgCES?
ty yes or not No
10a. PLACE OF DEATH (check onl y one see instructions
HOSPITAL II ER'Outpatient
on other side)
OTHER Nursing home Residence
El Ispe
Inpatient DOA I
we street and num�erl
Rochester Methodist Hospital
11. STATUS Married. Never
10c. CITY OR TOWNSHIP OF DEATH
Rochester
Y t OF H
10ouNToEAT�
O
y M u A ,n RITAL Married.
Md=iwid orced (speedy)
136.X1ND OF BUSINESS.9NDUSTRY
12. SPOUSE Name Id wile. give maiden name) e
John G Hampshire
13a. DECEDENTS USUAL OCCUPATION (give kind of work done
Qualf2ttyl obrifividoto nrri isettor
Pacific Chrom lox
1 ET 1y
4 S RE lk t IVD O gany
14a RESIDENCE State
WY
146. COUNTY
Lincoln
14 c.CITYORT0VYNSHIP
Thayne
L Drive, P.O. $OX 8
16 PACE [see mst:ucnnns
CIA. iN p BIDE CITY or LIMITS 0
N Yes not t`r
q( j1 CQDE
3 1�
15. WAS DECEDENT OF HISPANIC ORIGIN?
(specify yes or no d yes, speedy Yes No
Cuban, Mexican, Puerto Rican, etc I
on other sidel
White
19 MOTHER'S NAME (lust, middle.
i7 DECEDENT'S EDUCATION (speedy omy highest grade r ompleted)
Elementary'Secondary 10 112 College I) 4 or 5 I
18. FATHER'S NAME Host middle, last)
Archie C. Sweetland
maiden surname)
Ida M. Truax
20a. INFORMANTS NAME Itypepnnll
Mayo Clinic Records
20b. MAILING ADDRESS
Street and Number or Rural Route Number, City, State, Zip Cndel
200 First Street, SW
Rochester, MN 55905
21. METHOD OF 0ISPOSITION
Cremation Removal Ho stale
ID Burial Horn Donation Othtf Isper:flyl
216 PLACE OF DISPOSITION
21c. LOCATION Coy 1st Township.
[name of cemetery, crematory.
Washington Heights
226. LICENSE NUMBER
or n:her place)
23. NAME
State
Ogden, Utah
22x. SIGNAT OF NERAL DIRECTOR �r pTICIAN
f ol Funeral Eslabhshmentl
0228
AND ADDRESS OF FUNERAL ESTABLISHMENT
Macken Funeral Horne
OEne Inc
1105 12th Street SE, Rochester, MN 55904
11a C 6 `J u y 11”
I attended ded thhe e deceased eceased from to
and day year mo day year
09/22/95
and last saw hitem
246. SIGNATURE Physician Medical Lnammer or Coroner
1/� 1�
a
25, A E AND
21t. LICENSE NUMBER
lot physician)
24276
24d. DATE SIGNED
Imonth, day. year)
09/26/95
mo day year
I Id, •did not view the body aye, death
ADDRESS OF HYSICIAN MEDICAL EXAMINER OR CORONER
Wi D. Edwards, M D
Edwards,
In /For the Mayo Clinic
Rochester, MN 55905
r. CAUSE OF DEATH
26 TRAR'S SIGNA
fi1
27 0*1 LED lmomh day. year)
r O" -q
PART 1 Enter the diseases, intones or complications thal caused the death Do
enle the mode of dying, such as cardiac or If diagnosis deterred 1 Apptoanmate interval between
respiratory arrest, shock, or heart 'allure list only one cause on each tine
Check box onset and death
IMMEDIATE CAUSE Gastrointestinal hemorrhage and sepsis syndrome.
Ifinal disease or condition a
resulting on death) 6 Esopnagegr
Sequentially h d sl conditions. any,
leading to immediate cause Enter b
UNDERLYING due to
CAUSE Idfsease or or as a consequence of
mom thatrmh s'
ated events P rimaV biliary cirrhosis.
resulting m death, L c
PART 0. OTHER SIGNIFICANT CONDITIONS contnbuhng to death but not resulting in the underlying cause given n. PAR( I 29a. WAS CASE REFERRED TO
MEDICAL EXAMINER
CORONER?
30 MANNER OF DEATH Yes $2 No
296. WAS AN AUTOPSY
PERFORMED?
Yes a�g. No
29c. WERE AUTOPSY FINDINGS
AVAILABLE PRIOR TO
COMPLETION OF CAUSE OF DEATH?
Yes KCNu
atural
31c. INJURY AT WORK?
Accident lo Pending Could not be
Homicide investigation determined
31a. DATE OF INJURY
Imonth. day year)
316. TIME OF INJURY
M
Yes No
31e. PLACE of INJURY At
31d. DESCRIBE HOW INJURY OCCURRED
home )arm,
street factory, office building, etc (specify)
s '.yykt8104
Yv 11 1
1 311. LOCATION (street and number city or township, slate)
A
02
LOCAL FILE NUMBER
d l' OF 0uvrpltD.
this to be atti.16 copy of
n „I record i 'my custody.
a,;' o
J arnw.''' 1
9 s
e, RQiil4 "Ca
.74„ corded
MINNESOTA DEPARTMENT OF HEALTH
Section of Vital Statistics
CERTIFICATE OF DEATH 128079