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Home My WebLink About973630STATE OF WYOMING ss COUNTY OF LINCOLN AFFIDAVIT FOR DISTRIBUTION OF DECEDENT'S PERSONAL PROPERTY PURSUANT TO W.S. 2 -1 -201 0153 I, JAMES DAVID REEVE, 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 a distributee, as hereinafter set forth, that I make the following statements in connection therewith: 1. That BARBARA B. BELCHER became deceased on January 8, 2007 in Concord, Cabarrus County, State of North Carolina, and was a resident of Cabarrus County, State of North Carolina, at the time of her death; that said decedent died testate; that said decedent left William John Reeve, Timothy Allen Belcher, James David Reeve, Carol Ann Arvanites, and Susan C.B. Aschenbrenner, as surviving heirs; that the sole and only parties entitled to the estate of said decedent are the distributees 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, in Wyoming, does not exceed $150,000.00. 3. That more than thirty (30) days have elapsed since the date of death of the decedent. 4. That the following named distributees are the sole and only parties 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 distributees are entitled to payment or delivery of all of the decedent's property; RECEIVED 10/8/2013 at 10:18 AM RECEIVING 973630 BOOK: 822 PAGE: 153 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY Name Relationship William John Reeve Son Timothy Allen Belcher Step -Son James David Reeve Son Carol Ann Arvanites Step- Daughter Susan C.B. Aschenbrenner Daughter Affidavit for Distribution Page 1 of 3 5. That among the assets owned by said decedent is the following: COMPANY Beartooth Oil Gas Co. P.O. Box 2564 Billings, MT 59103 More particularly described as: ACCOUNT TYPE BALANCE Overriding royalty interest 800.00 Owner #8792 Craven Creek Unit Lincoln County, WY Federal Oil and Gas Lease W- 0312801. covering Township 24 North, Range 114 West, Section 14: N1 /2N1/2 and Section 15: N1 /2NE1/4, NE1 /4NW1 /4 in Lincoln County, Wyoming TOTAL ESTIMATED VALUE $800.00 6. That an executed copy of this Affidavit is being presented to the transfer agent for the above listed assets 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 distributees listed here. Name Address William John Reeve Timothy Allen Belcher James David Reeve 825 Mainsail Rd. Salsibury, NC 28146 Carol Ann Arvanites 342 Plant St. Gorton, CT 06340 Susan C.V. Aschenbrenner 3620 Old Airport Rd. Concord, NC 28025 Affidavit for Distribution Page 2 of 3 560 Old Westminster Pike, Apt. 2 Westminster, MD 21157 289 Main St., Apt. 9N Spotswood, NJ 08884 0154 EXECUTED this 0 5 day of S L e STATE OF NORTH CAROLINA COUNTY OF 0.-abct (:I& My Commission Expires: ss. ES DAVID REEVE SUBSCRIBED AND SWORN to before me, a Notarial Officer, by JAMES DAVID REEVE this A7`f 1) day of y. 2013. .rAstil.'.I I a NOTARIAL OFFICE 6, )6d Affidavit for Distribution Page 3 of 3 2013. i NS 1::::: z t t s 1 tA f A 0 I i ,.;gRRUS G 3�� 0 :'5 5 y R�oZ}' f ew M „4;4 :.r.. -Writ �r �/�r +��%r �V S •L �`S{ t r v •so. r..• s:. rs r -r. s..., .•ss. ar t. -`1 1Z4 .r l.',. s: 1/� V O. 111.7 QV� 1 i; 4 a 4• *AV's" V: N �iO: N riO +ir�i �i0:0�� 1'N`�i•. O:•y i Ii V j i i� e.. tit 1 141 111 IMI 111 4 11 .1 11 1 11 1 4 1111 r 41 11+1111 f/1 4 141 f N,' 1 141 t f t h4 II� 4'h 411 do 1111+ t t1/1 :11 111 t 111 n r t 111 TrTr J CERTIFICATION OF VITAL RECORD t �rftfrt t ��fk t�� h REGISTER OF DEEDS OFFICE, CABARRUS COUNTY, NORTH CAROLINA 13a. NC Regis tration District No.t„s� �V Local No. DECEDENT'S NAME (First, Middle, Last) 1. BARBARA BOOR BELCHER SOCIAL SECURITY NUMBER AGE- Laet.Birthday UNDER 1 lVearsl Months s. 73 WAS DECEDENT EVER IN U.S. ARMEDFORCES ?:(Yes or No)' a. NO HOSPITAL:.❑ Inpatient:..❑ EFVOutpatieflt DOA OTHER: Nursing Home Qesidence FACILITY NAME Of institution, give street and number) CITY, TOWN; FOR LOCATION OF DEATH: INSIDE.CIT'Y LIMITS? (Yes or No) ea. NO 9b. 3620 OLD AIRPORT RD 90. CONCORD 'MARITAL STATUS Married Never SURVIVING. SPOUSE Of wife, give Malden name) Married, Widowed, Divorced (Specify) .1 MARRIED i ROBERT BELCHER RESIDENCE -STATE COUNTY CITY, TOWN, OR LOCATION INSIDE :CITY LIMITS? ZIP CODE rBa NO 1 28025 13e. 13f. FATHER'S NAME (Firs Middle, Last) VLADIMIR BOOR 17. IMMEDIATE CAUSE (Final disease or AUTOPSY? (Yes or No) Certificate if NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES N. C. VITAL RECORDS CE OF DEATH DUE TO (OR AS A CONSEQUENCE OF): DUE TO (OR AS A:CON EN SEcIUCE OF): R Days If'yes, Were finding considered in determining cause otdeath? 114 S'"1 CA. ce r Hours 5c. 13btABARRUS. 13c. ,CONCORD Was Decedent o :Hispanic Origin? (Specify Yes or No -If yes, Specify Cuban, McRtcan, Puerto Rican, etc.) Yes I '4o ((Specify) 19. 21c. Minutes 15. 23a. NAME AND ADDRESS OF PERSON WHO O COMPLETED OFD 1H ((IITEM�, (Type or 24 ll�Vl.O0A 0 rY J r v t Z IQ 1� ,,e .1 �'tf G1J METHOD OF DISPOSITION 0 Burial .Cremation Removal 25a. 0 Donation r NAME AND ADDRESS OF FUNERAL HOME 26 WILKINSON FUNS AL REGISTRA S SIGNATURE Witness my hand and official seal this the day of PLACE OF DISPOSITION (Name of cemetery, crematory,. or other CRENIP„TORY CONCORD ,N 25 DATE FILED (Month, Day, Year) 28JO halt J 4 eath SEX FEVIAT4a, JAN. 8,2007 DATE OF BIRTH(Month, Day, B)RTHP..LACE (Cogpy and S Year) or Foreign Countr4 6. SEPT..16,1933 T. TJNT.ON CO. NJ 9a. PLACE OF DEATH (Check only one) .DECEDENTS USUAL OCCUPATION (Give kind otwork KIND OF BUSINESS/INDUSTRY done �dudn most of working life. Do not use retired.) 128REG NURSE 120. DOCTORS 'OFFICE. STREET AND NUMBER 13d.::3620 SOLD AIRPORT RD RACE American fndian DECEDENT'S. EDUCATION (Specifyon(yhighest glade Black, WNte, Etc. (Specify) completed) Elementary/Secondary (0.12) College:(13 WHITE 17 BY 16. MOTHER'S NAME (First, Middle, Maiden Surname) Eleanor TeriEyck 18. Other (Specify) MAILING ADDRESS (Street and Number or Rural Route Number, CiCity or Town, State; Zip Code) 3620 OLD AIRPORT RD CONCORD,NC 28025 19b. INFORMANTS NAME (Type /Print)' .SUSAN ASCHENBRENNER 19a. Part 1. Enter the.diseeses in(udes, or complications that caused the death. Do not enter the mode of dying, such as cardiac or resptratory;arresf,shock or head failure. ?II appreerlate; tobacco, alcohol, or drug use. LIST only one cause on each line. (PRIArr or TYPE DATE OF DEATH (Month, Day, Year) COUNTY OF DEATH 9CABARRUS condition resulting DUE TO (OR AS A CONSEQUENCE OF): in death) Sequentially Ilst conditiona if any, leading to immediate cause. Enter UNDERLYING CAUSE (Disease or In)ury that Initiated events resulting In death) LAST. 20a, d. Part 0. Other significant conditions contributing to death but not resulting in the underlying cause giverpir, Part I, such as tobacco, alcohol, or drug use; diabetes, etc. y 20b. Was case referred to Medical Examiner?: (Yes or No).. 21a. 21b. NOTICE. STATE LAW REOUIRES THAT ALL DEATHS DUE TO TRAUMA, ACCIDENT, HOMICIDE, SUICIDE, OR UNDER SUSPICIOUS, UNUSUAL OR UNNATURALCIRCUM TANCES BE REPORTED TO, AND CERTIFIED BY A MEDICAL EXAMINER ON A MEDICAL EXAMINER'S CERTIFICATE OF DEATH. ANY DEATH FALLING INTO THESE CATEGORIES 15jWITHIN THE MEDICAL EXAMINER'S! JURISDICTION REGARDLESS OF THE LENGTH:OF SURVIVAL FOLLOWING THE UNDERLYING INJURY. SIGNATURE AND TITLE OF CE�gTjA{FFIIEA DATE 51 NED (Month, Day, Year) 1 14. 37 23b. NAMED 26b. Moor'svi1(2, J1c, 28117-- LOCATION City or Town, State, Zip Code 25a ItANNAPOLIS,NC 28081 FUNERAL DIRECTOR NAME OF EMBALMER 26d. 'NOT EMBALMED 1 do hereby certify that the above is a true copy of the death certificate 'on file in this office for the individual named hereon. Linda F. M�Ab Register of Deeds Deputy /Aseiste nt o 56 DATE AMENDED 19c. Approximatelnterval Between Onset anand TIME OF DEATH 22. M. LICENSE NUMBER 2G261781 LICENSE NUMBER 26e,. 1 ♦O•♦ 14 I 1 111 1 1 1 ;+.10 o• x4.411 h4 Is 41 ii re; II 740 ,,c,,_,,. .l t!-1 !it ,*:..t.or [-L-'11:7'. O) iti r I .4 11); d V i: o ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE tf 40, l f I J yJrb ��nt r �rl di% r r 4 rr 1 11 4 1 1 1\ %4 !y 0 '011 f If1\ r t 11 .Iii a f 1 4'! 1 1 I +t1 �i•�j' 4�e+ t•• I+ 4/ 1111v,iii,4. 1. eii4.�iii.. �•ii� 1 ........0...... ..444 ...44.1. +_�Oi•Oil.!4R'.0ii• �1* I*++ i• �0��1 !•+4,0i0O•i�h1tR4►�iii�J.1f�� :t /11�+9•••��iw`I(J �S 16.5� OSy�•••�•t• i:•�rtG tiy yy •.y SV t k...i 9:i$••. S'.S.i'•!' y +:yi' .'b'�.�:t' S:L4 ya�"!� .'.r r s ra ar s'� r ar„ %��""n��- +..z��:si.�� z��: r� si��si� ir��-.:��i��ii��s