HomeMy WebLinkAbout973400When recorded mail to:
Elizabeth Janette Beck
PO Box 32
Churdan, IA 50050
AFFIDAVIT AND ACCEPTANCE OF TRUSTEESHIP
Comes now the undersigned Elizabeth Janette Beck and being on oath first duly deposes and says:
1. That I am a citizen of the United States of legal age and capacity, and competent to make this affidavit.
2. That I was personally acquainted with the deceased, Elmer Abel Beck
3. That said deceased is one in the same person as Elmer Abel Beck listed in that certain document as
recorded on April 4, 1991 at Entry No. 730641 in Book 295PR at Page 407 in the office of the Lincoln
County recorder, State of WY.
4. That the purpose of this affidavit is for Elizabeth Janette Beck to accept the Trusteeship of the Beck
Living Trust of 1990 and hereby agree to act as Trustee 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 10 OF STAR VALLEY RANCH PLAT 14, LINCOLN COUNTY, WYOMING, AS DESCRIBED ON THE OFFICIAL MAP
AND PLAT THEREOF FILED AUGUST 10, 1977 AS INSTRUMENT NO. 496705 IN THE OFFICE OF THE LINCOLN COUNTY
CLERK.
4 a� L 8 SHELLY T. EMUS ll Commission Number 193943
My Commission ExpiAs
oWo. December 12, 20 42
lizabe h Janette Be k
State of
County of ei'P _p_pQ ss:
On September /9 2013 personally appeared before me Elizabeth Janette Beck, and the signer(s) of the
within instrument, who duly acknowledged to me that They executed the same.
T
Notary Pint
Commission Expires: /6 '/a"/
RECEIVED 9/23/2013 at 3:10 PM
RECEIVING 973400
BOOK: 821 PAGE: 104
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
3A. AGE- LAST BIRTHDAY'`
3b. UNDER 1 YEAR
3c. UNDER DAY
4. DATE OF BIRTH(Month, Day, Near)
16, 1924
B. COUNTY OF DEATH
Polk
U.S.
2. SEX
Male
86 Yarr
Months I Days
Hours I Minutes
8. PLACE OF BIRTH (City Stale, or Foreign Country)"
San Diego, Califomia
7. SOCIAL. SECURITY NUMBER
I
B. CITIZEN OF WHAT COUNTRY
aes
Un ited States
9. EVER IN
R O.FORCES?
Ves No
115. MARITAL STATUS AT TIME OF DEATH
31$ Married Marled but separated ❑Widowed
Never Married ❑'Unknown
106. DECEDENT'S LAST NAME PRIOR TO ANY
MARRIAGE( f ever married)
Beck
11. SURVIVING SPOUSE (Full name prior to any marriage)
Elizabeth Janette Brooks
Divorced
12. RESIDENCE -STATE
Iowa
128. RESIDENCE COUNTY
Polk
12o. RESIDENCE -CITY OR TOWN
Des Moines
I,. unrucom
12d. RESIDENCE- STREET NUMBER, zIP CODE
935NE 51st Street, 50313
FIRST MIDDLE LAST
12.. INSIDE 7
Yes C7 No
'7>
z
0
1-
0.
0.
(/2
0
BIRTH'
NUMBER
W
0
1. DECEDENT'S
FULL NA
0
0
0)
U.
20111505
Ilia IL 1 J
CERTIFICATION OF VITAL RECORD
STATE Q-F IOWA.
FIRST
County Record
STATE OF IOWA
IOWA DEPARTMENT OF PUBLIC HEALTH
CERTIFICATE OF DEATH
MIDDLE:
LAST
Beck
114-
SUFFIX, If any
13. FATHERS
NAME
159. INFORMANT'S
NAME.
FIRST .MIDDLE LAT
Abel
Liz Back
18. PLACE 08DEATH(CneCN only one)
F DEATH OCCURRED IN A HOSPITAL IF. T,H2OCCURRED SOMEWHERE OTHER THAN A HOSPITAL
Inpatient ER/Outpatient Dead on AArrivalI Hospice Facility Noising Homellong -Term Care Facility ❑Decedent's Home
t 7a. FACILITY NAME (If not Institution, give sheet and number)
Taylor... House
18. METHOD DISPOSITION 1.
Burial IOrema(lon Donation 0 Entombment .Removal from Stale
Other (Specify)
20. LOCATION OF DISPOSITION (City 'orTown B. Slate)
Des Moines, Iowa
22a. FUNERAL ((RECTOR -Printed Name
Steve Raynond
ITEMS 24 -28 REQUIRED TO BE COMPLETED BY
PERSON WHO PRONOUNCES OR CERTIFIES DEATH
48, NA P E MAILINGA" ES
r
1 50. FOR REGISTRAR ONLY/AEG r TRAR SIG AT
Beck
15b MAILING ADDRESS (Street Number, City Stale, Zip Code)
935 NE 51st. Street, Des. Moines, lows
26. NAME OF PERSON PRONOUNC O DEATH (If dlNoranl than (Type oror do p 9 .Y)
(MD, DO, PA, ARNP, RN LPN)
29. ACTUAL OR PRESUME0' DATE, 'OF DEATH. .P
(MOnlh, Day, Year) (Sp II'dui'month) September 17, 2011
NAME PRIOR
TO ANY MARRIAGE'
17h. CITY, TOWN, OR LOCATION 6 ZIP CODE OF DEATH
Des Moines, 50317
117o. INSIDE CITY LIMITS'
Yes' 0 N
DISPOSITION
Junlatta
Johnson
15. RELATIONSHIP TO DECEDENT
wife
Other(Specify)
19. PLACE.OF DISPOSITION. (Name of Cemetery, Crematory,
Hamilton
or otherpla0e)
PL Crematory,
i
21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY
Hamilton's near Highland Memory Gardens, 12
60th Ave., Des Moines, Iowa 50313
E
22b.,FUN DIRECC_OR' -SIgnature
PRONOUNCEMENT, d AND C/5JSE OF DEATH':'
24. DATE PRO OUNCED 0EAD month),
(Month, Day, Veer) (S ell out mon
.11 r L1
27.7(710
30. C UAL R PRESUMED TIM E6E,D0ATN
TIME tD0S AM 0 71eK III(ary
25. TIME PRONOUNCED DEAD
TIME' 1 1� {<5 AM 9�
PM SSmniI95
LICENSE NUMBER 319. MEDICAL
EXAMINER
CONTACTED Ves No
28. LICE
229. LICENSE NUMBER
2692
32a. PART 1 Enter the balm of evens- diseases, In)udea or comp11ca(ipnc that Grady caused Ole death.00 NOT enter lermina)eveplasuch as cardiac erre°I,
(aspiratory arrest, or ventricular fibrillation without snowing the etiology: DO NOT ABBREVIATE Enter only one cause one (Inc. Add a
ddldonal (Ines If necessary.
IMMEDIATE CAUSE (Rnal disease or w �y..�`�tr• to (or cgldtlon resulting In death) a. k e�ll+
Du to(orasaconsequence*
Sequentially list conditions. Ilan, leading to 4.
(A".0cou r0ar 1s4a°' W"
the cause (sled on lines Enter the Due to (or ate consequence'o0r
UNDERLYING CAUSE(disease or Injury that
M11(9104180 events resulting death) LAST
'Due to (ores a consequence 0Q:'
Due to (or as a consequence of):
316.11708,15.E. case number
3241. Approximate
Interval between onset
and death
r \iNWY�
AAmi 1n.5
33. WAS AN AUTOPSY PERFORMED? Li Yes ale
34.11 Yes, WERE AUTOPSY FINDINGS AVAILABLE TO
COMPLETE CAUSE OF DEATH? Yes No
37. MA NER OF DEATH
Natural Homicide
Accident Pending Investigation.
Suicide Could not be Determined
32c. PART II Enter other slonl09ant conditions coNributino to ddeealbul not resulting in the underlying cause given in PART 1
-e444./.v w (A in x4.6141; d AcovTw S✓t(e)Aos S
35. DID TOBACCO USE 36. IF FEMALE:
CONTRIBUTE TO DEATH? Not pregnant within pest year Not pregnant, but pregnant within 42 days of death
Yes r Probably El Pregnant at Ome of death Not pregnant, but pregnant 43 days (01 year before death
No t� /Unknown Unknown g pregnant within the past year
38. DATE OF.INJURY (Month, Day, Year) (Spell out month) .138. TIME OF INJURY AM U PM 140. PLACE OF INJURY (e.g., home, farm; street, roadway, eta)
TIME 011( 1 a �'1 I
IFTRANSPORoATION INJURY, SPECIFY:
I B D nver r o peralor Passenger Pedesldan
Other Seedy)
141. INJURY AT WORK?
Yes No
42. LOCATION OF INJURY: Complete physical address Street B Number, Apt. 8, City or Town, Slate, Zip Code)
44. DESCRIBE HOW INJURY OCCURRED:
45. CERTIFIER
(Check only one)
Signature
Certifying MD, D
Medial Ezaml
ARNP -To the best of my knowledge, death occurred al the time, date, and place, and due to the cause(s) and manner staled.
-0n the basis of ezaminalidand/or Investigation, In my opinion. deal occurred at the lane, data, and place, and due lathe au$ (s) an staled..
.D 46.TITLE m4 47. DATE CERTIFIED (Month, Day, Year) 1.
1
TI O
G PHYS IAN 0R MEDICAL EXAMINEE 49. LICENSE NUMBER
a O Yi 4o( t. 1)0CE s Swl Ili an 1 '3T5
Oa, DATE RECEIVED REGISTRAR (MO, Day, Year)
SEP 2 3 2011 (MOM,
This is to certify that this is a true and correct reproduction of the original record as recorded
in this office, issued under authority of Chapter 144, Code of'Iowa.
This copy not valid unless prepared on engraved border displaying state seal and signature of. the Registrar.
SAP -2 6 201.1
p BY 6( OF POLK
DATE ISSUED COUNTY REGISTRAR OF VI RE(, "RDS COUNTY
C3 377046
FORM 4588-0328C (07/2007) WARNING: IT,IS ILLEGAL TO DUPLICATE THIS COPY