HomeMy WebLinkAbout972997STATE OF WYOMING
SS.
COUNTY OF LINCOLN
COMES NOW ROBERT K. JONES, SURVIVING TRUSTEE of THE R D JONES FAMILY
TRUST dated March 31, 1993, as amended, who, being duly sworn and under oath, states as follows:
1. That The R D JONES FAMILY TRUST dated March 31, 1993, as amended August 28, 2013,
hereafter, the "Trust continues to exist, and has not been revoked, modified, or amended in any manner that would
cause the representations in this Affidavit to be incorrect.
2. That the Settlors of the Trust were Robert K. Jones and Diane B. Jones and the original Trustees
of the Trust were Robert K. Jones and Diane B. Jones, Trustees.
3. That Diane B. Jones died on June 25, 2013. An official copy of the Certificate of Death issued by
the State of Idaho for Diane B. Jones is attached hereto.
4. That the current and sole Trustee of the Trust is the Surviving Trustee, Robert K. Jones.
5. That this Affidavit is made pursuant to, and in compliance with, the provisions of Wyoming
Statutes 34 -2 -122 and 34 -2 -123.
6. That the undersigned Affiant: (a) knows that the matters herein stated are true; (b) is duly
authorized to execute this Affidavit; and (c) hereby indemnifies any person or persons against losses, damages,
costs, and expenses of every kind incurred by reason of reliance on the statements made herein.
DATED this 28th day of August, 2013.
SUBSCRIBED AND SWORN TO before me this 28th day of August, 2013 by ROBERT K. JONES,
acting as Surviving Trustee pursuant to authority provided to him in The R D Jones Family Trust dated March 31,
1993, as amended August 28, 2013.
WITNESS my hand and official seal.
M KEVIN VOYLES NOTARY PUBLIC
County of
Lincoln
State of
Wyoming
My Commission Expires: July 16, 2015
My Commission expires:
AFFIDAVIT OF TRUST
OBERT K. JON S,
SURVIVING TRUSTE
RECEIVED 8/30/2013 at 11:57 AM
RECEIVING 972997
BOOK: 819 PAGE: 265
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
0° 65
TYPE OR
PRIM IN
.:PERMANENT
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BELT T P PEN:;
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HA1140000
U 1L, INFORMANTS NAME (Type or ping)
DISPOSITION
ITEMS 3230
TO SE. USED
FOR EXTERNAL
CAUSES ONLY
ORONc
YIFDEATN WAIL
:.DUE'T° OTHER:
::'THAN NATURAL
THE CORONER
51U57
COMPLETE AN0
EION ?NE
d.EJ11'JIdATE
PLACE OF
DEATH
DATE Of
DEATH
CAUSE OF
DEATH
:State of. Idaho
`CERTIFICATE OF DEATH
ue. n a aao, 151 R.rP.coer L C3.[R9 N..
1 DECEDENTS LEGAL :NAME N clod ANA'c f a y) (fSNI,, Middle', Last. Suffix) :f Zr SEX (],:SOCIAL SECURITY NUMBER."
L DIANE B. JONES FEMALE
N a
:slid Slate. T rtilo ok FOYN i C
O M A 1 &rmd y db UNDER 1 YEAR 4CUNDER 1 DAY 6 DATE OF BIRM (M01DaY4Yr i..RIRTNPI Iclty, ry, p Iryl I ry
mu es I
79 r Months Days Hours (max.) i I 06107/1943 OGDEN, UTAH
ie I O E
ry TA RE •STATE OR FORLGN�COUNTRV !Tb. COUNTY i7c CITY OR TOWN
us: WYOMING LINCbLN' r STAR VALLEY RANCH
2 Td S TREETANDNUMBER;•: 1 1e APT NO;: ill S IP CODE
84`00TTONWOOD'LA NE 831Z7•'
L STATUS AT ._i__
N MARITAL TIME F TN E O DEATH 9.$IIRVMNfa SPOUSE'S N4ME'(II.WNa Pr
LL
:c MS d D 40,0404)404 separated D widowed D 000,0.4 D N mar d D Unknown ROBERT K'JONES :i 1
:Is' illE
1p EVER INU.$ FATIlER•$ NAME (Fnl, Middle. Suffix) 11'b, BIRTNPUCE (Stele, Tarlary, a Foreign CounlrjN"
F GEORGE E. B
'130 RELATONSNIP TO DECEDENT 1 1Da. MAILING ADDRESS (51 1 and.NUmbe C ly Stele: zip Coda)
Z ROBERT K. JONES HUSBAND P.O BOX 5247 ETNA WY 83118
of ry, ....1
camelary, 16. NAME AND COMPLETIAOORESS 60':FUNERAI'EACILITY
BUCK MILLER -HANN FUNERAL HOME
1 825 EAST 1:jTH STREET
IDAHO FALLS IDAHO 83404
_i 17b UCENS NUMef]t(O(Iica see) 79. WAS CORUNp(OONTACTED';'
OUE 70 CAUSE'CF OEATH7.
I :M07.5 ONO
195. IF DEATH OCCURRED IN A HOSPITAL: 19b. IF DEATN OCCURR®
SOMEWHERE OTNER THAN A HOSPITAL.
„11 MET;N0o OF DISPOSITION 76, PLACE OF DISPOSITION (Name and addrece
s w story; other Dlzce)
Buhal Cremat
Entanb r :,BCACKFAOT CREMATORK
D d ovai!iro Id ho .:'132 S.'SHILLING
221
011ie (SOe BLACKF00T IDAH083
17 SIGNATURE OF FLINERALSERVICE OR PERSON A CTING A SSUCN
ELECTRONICALLY F ILED: KEVIN WBOOILV
27 DATE :OF DE4TH (MU/Oay/Yr) (SOO rd(nh)
'x'29 OID TOBACCO USE
CONTR(BUTB' TG DEAN?
O. 0 Y.o::.'.,[] P bably:,:,
El No DUnknown
U
—'36 LOCATON'OF INJURY:
,40.:.REGISTRAR'S SIGNATURE
'STATE OF;IDAHO
IDAHO DEPARTMENT OF HEALTH AND :WELFARE
BUREAU OF VI TAL RECORDS AND HEALTH STATISTICS":.
IISIPMFIMIL 2 EFWJ Iwo M q facility S Nursing hohome/Long o
p Term re facility 6 Decedent's h 70 011ie ($pedN)
O]
20 FACILITY NAME7N (Ig 1 ty, ploestreel; d h b 2 21 CITY .TOWN, LOCATION OF DEATH, AND ZIP F C'22. COUNTY DF DEATN
EASTER}! IDAHO RI50IONAL MEDICAL.CENTER IDAHO FALLS I0 53404 BONNEVILLE
24. 714080F DEATH I 292 DATE PRONOUNC® DEAD (40 /D y4/)(Sp011'mo Ili) 26. TIMEPRONDUNCED O
PART I. Enter (he chain of events —diseases, in(unes. or com011oaeons —Ihal dlrec(y GOaed the death OD :NOT enter4ann)ilal events su 11'asianyiac
arryR;la5Piratory arras'. of venldcular 15411.lion wilhoul showing the ellobgy. 00 NOT ABBREVIATE. Enter only one cause on a fine; 1
IMMEDIATE.CAI)BE,{Flnal I
ATHERO'SCLEROTIC DISEASE
P D U E TO(or ae a wnseduenaot)i
nt seam)
y1Dno ((8(1911/00)111/ o ,ti ISCHEMI,C BOWEL
f any, Teliding 10 the 0 5e :i AUE TO (or as a 0Ar169511e1100 oh:
''N1a n1Ma; 11 IC Ih
UNDERLVING:CAUSE ACUTE' RENAL FAILURE
O
,LASTe awry DUE TO (or o
C Ihal irrigated sled d the the events
fasuning In death)
d.
PART II E ,le other y
ersignifinl cdndiUOns cpnlnb 1 O to death Sul not resulting in the underlying reuse given n In Part) i 3B. W Aft AED
i
PERFORMED?
30 IF FEMALE (A0 d 19.64) D ysa No
Ngkirregnant3NOWI wog 9eir D Not ornanink Mil .p a 143 de y J1. MANNER OF�DEA
0 Piep a 1 11 FPf 485111 l0 1 yea .bebre'da Ili ®Na4Ureg
D Nnt•P p 1 but 1105,.1 0414000.10410 nenl U th ,p 0 ...'*!4•^
within 42 days. Of death 4001 0 'SNtld
1 33. TIME OF INJURY 1 34. PLACE OF INJURY (Do0.denl's hoiH0•enn, sl'ra4lobcpalruolion site
(240')' nursing home. restaurant Ioraal, etc.)
City/ Town or GgiinN
This is a true andcorreot reproduction of the document officially registered and pladed
SEA 'On file with`fhe IpAHO:BWREAU OF VITAL AND HEALTH STATISTICS.
,I. .I y,
MA 1 1. S
0,116e Eia§s of 6■0n and/of 14, vesigal AMyopnl40 d 105G.4rred 1.61fittkne..d6101.and 1400 and due M Ili cause(al:r
and mEnner s fed,...
Signature and in of Certifier k PATRICK 0 GORMAN, M D.....
394. NAME, ADDRESS AND DP CODE OF CERTIFIER RTIFIER (Type or print)
.PATRICK D. GORMAN, 2001 S. WOODRUFF AVE. STE 12A IDAHO FALLS, ID 83404
i %T DATE ISSUED:
This oo
�i�? :dis la my ved border
s tale not valid unl beaLa si pre pa nature of the engraved
Registrar.
PYS s s
PBNC 00'sN)IWJ$
.1.... 1. ilia., e. 1.11,. r. ...1 ..a,r.rrre,..r .0,1r,.,,1r.a11.,..: :.1:rM... r
3 WEEKS
2 -WEEKS
e
3eD.
AVAILABLE 1 CO MP LE T E
AVAILABLE 70 COMPLETE
THE CAUSE OF DEATH?
0 Yes D No
D Honikr Q
PB tlidgl Iig to
0 00 u49 :nbl14d 1 nrjinpd
:Sli9ifiand Numbs' or. Lpcalpn Ap n t Nu b
SCRUB cle
37, DEECRIBE HON CH I 44IC C g C E DEN
c aopl ON INJUR STATE THE TYPB(5) O Vp11C4E(5) INYOt.VED(AUl rtnb kr nkk p ommyda. AN bicycle, eta)
'SpECIFVWHCH VENN ;GE'DEC OCOVPIEQ': fapgicabb
TRANSFORTATON T 3Ba, WAS DECEDENT: 0 Driver/01.4mM, 0 Pease p r ub, WHAT SAFETY DEWCE S(S(otopECEDENT "USE/EMPLOY?
INJURY.ONLV 0 de D Other (s 44) i D Seal belt I 0 Child safely seal 0 Helmet 0 AI hie D None D Unk
'39 CERTIFER (Chedron4Y'ono band onoffiool/ p ckyfgplha cellficale) 39b. LICENSE NUMBER
PHYSICIAN PHYSICIAN ASSISTANT 0 ADVANC.EOPRACTI,C.E PRCFESSIONAL NURSE..
To 414014 e8 of my knowledge: death oc04 lOd al the 'kite'; datri 444 ate' Aiid du5l5 the fifth) 09 59(e)/man a salad:.:
JAMES B:'AYDELOTTE
STATE REGISTRAR..
E. o
mita vim M oggo■ i [1�
CERTIFICATIO TAL RECORD
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