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AFFIDAVIT L_ PENALTY OF PERJURY FOR ...r' ACCOUNT
OR PERSONAL PROPERTY WITHOUT COURT ADMINISTRATION
WYOMING STATUES SECTION 2 -1 -201 ET SEQ.
(FOR ESTATES WITH A TOTAL VALUE OF $200,000 OR LESS)
NOTICE TO BANK: MUST BE FILED WITH COUNTY CLERK AND BANK MUST RECEIVE A CERTIFIEED CC
PRIOR TO ANY DISTRIBUTION OF ASSETS.
1 /We [Enter name(s)] Il4har B. PIZ( (t_ (individually
and jointly "Affiant whose address(es) is /are: (Attach additional sheets as needed) LA J N k/ tf I &ci
5 2a.. i 13 i Po toq K'et nw tub 8301
declare to Bank of the West "Bank that the following is true and correct:
v 1_,ST
1. (Name of Deceased) Em L I" h. O
3a L VE County of Sail l State of Ll 6 c_ .'`1
on (Date) 7 b-7 I do /3
(the "decedent died in the City of
2. At least thirty (30) days have elapsed since the death of the decedent, as shown in a certified copy of the decedent's death
certificate attached to this affidavit.
3. No application for appointment of a personal representative is pending or has been granted in any jurisdiction.
4. The current value of the decedent's entire estate, wherever located, less liens and encumbrances, does not exceed two hundred
thousand dollars ($200,000).
5. The claiming distributee(s) are entitled to payment or delivery of the property by virtue of the following facts concerning the
distributee's relationship to the decedent: Distributee(s) are: [Check appropriate box(es)]: Parent(s); Spouse; Child(ren);
Grandchild(ren); Sibling(s); Child(ren) of Sibling(s); Aunt(s) /Uncle(s); Heir(s) under will; Heir(s) at law;
Trustee of trust taking under a pour -over will; Other Describe:
There are no other distributees of the decedent having a right to succeed to the property under probate proceedings.
6. At the time of the death of the decedent, the decedent was the owner of certain personal property held by Bank of the West, which
personal property is described as follows:
(a) Funds on deposit in the aggregate sum of 526/e, Y1 hbciaC[ivc�'
i'ePay• 1 rs
7 in the following accounts:
Branch Name City /State Account No. Amount
K e (An wl6veAt 1-<e v1n w te- buy a-
(b) Personal property situated in safe deposit box or vault no. or held in safekeeping at this branch; (Enter
Branch Name and State)
(c) The decedent's interest in: (Describe)
(continued)
RECEIVED 9/13/2013 at 12:11 PM
RECEIVING 973242
BOOK: 820 PAGE: 243
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
7. The affiant is entitled to payment or delivery of the described property, has the relationship described below and requests that the
described property be paid, delivered or transferred to affiant(s) directed as follows:
Name and Address
1)
2)
3)
4)
Relationship to Decedent
Proportion Due Each Distributee
8. Affiant is the successor to the decedent's interest in the described property or is authorized to act on behalf of the successor of the
decedent with respect to the decedent's interest in the described property and no other person has a superior right to the interest of
the decedent in the described property.
9. If there is more than one affiant, all statements in this Affidavit are made individually and jointly.
10. In consideration for Bank's honoring this Affidavit, Affiant(s) agree(s) that Bank cannot be held liable for giving
Affiant(s) the money and /or property described in paragraph 6 and agree(s) to indemnify Bank and hold Bank harmless
against all liability, loss, costs, damages or expenses, including attorneys fees, which Bank may incur by reason of its
honoring this Affidavit. A receipt for the payment by each of the distributees shall constitute a valid and sufficient release and
discharge of Bank of the payment made.
11. Affiant represents and warrants that Affiant has been advised to consult with legal counsel prior to executing this
Affidavit and that Affiant has had the opportunity to consult with legal counsel and has obtained such legal guidance as
Affiant has deemed appropriate prior to executing this Affidavit.
12. Each affiant affirms or declares under penalty of perjury under the laws of the State of Wyoming that the foregoing is true and
correct.
This Affidavit is executed on 1 3 20 13 in the City of
State of 1/1) /b» r
MUST BE EXECUTED BY ALL DISTRIBUTEES.
STATE OF /v1 d2'Y1 in
COUNTY OF t., 01
On S.C. 3 20 3 before me, the undersigned, a Notary Public in and for said State, personally
A r-?'i r 1 d�) ix/ 1
appeared
personally
known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s)is /are subscribed to the within
instrument and acknowledged to me that he /she /they executed the same in his /her /their authorized capacity(ies), and by his /her /their
signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS my nd and offici l seal.
Signature:
Affidavit Small Estate Wy
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mg
ienature
Signature
,.p,, a u m m.. .$.o.,.
Stdey A te t Lerner Notary P ublic
(Seal) County of
Seal)
Lincoln
My Commission Expires
Signature
Signature
State of
Wyoming
a-ad�5
030-05180 (Rev. 07/11)
1 CERTIIFICATIO
DECEDE IN FORMATION
Date of Death: Ju 27, 2013
City of Death: Salt Lake City
A ge: 48;:
Pl a c e of Birth; Rock Springs, Wyomin g;.
Arme Services No
Spouse's Nam Arthur Bert, Playle
Industry /Business Domes
Residence: Kemmerer „Wyoming
Mother's Name Lois Emmly Long,
Facility or Ad dress: U n iv e r sity of Utah Hospital
INFORMANT INFORM
Name: Arth Bert ,Playle;;
Mailing Address: P O B ox. 104, Kemmerer
FUNERAL HO INFORMATION
Funeral Home` Crandall Funeral Home
Address PO Box 6, 105 East Ceriter
Funeral Director:
EDICAL CERTIFICATION
Aedical Professional:,` John D Steffens,:
84132
ate Registered July; 30 2013
ate Issued July 30, 2013'
emoval•.
outh Lincoln Cemete
ugust 3, 2013
Time of Death:
County of Death
Date of Birth
Sex
M arital Status:
U suat Q ccupation
Ed ucatio n
F ather's Nam
F acility Ty pe`
07:00 (Found)
Salt Lake,
November 2T, 196:4
Female
Married
H omemaker,
High School or GED
Carl Orsen Eggleston”
Hospital; inpatient
usban
CAUSE O F DEATH
Cardioresp(ratory Arrest
Dueto or as a consequence of) Progressive Mu 'focal Leukoencephalopathy
T obacco Use Did not;Contr bute
M edibat Contacted:.,Ye AutopSy Performed No Manner of Death: Natural
1900 East Rm3R21,' Salt Lake City, Utah'
v
or�H elth T k
Off
Dist ict Health Department
�L P1 N iy '47
c e t a. f tt.t a ry ss