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°II
STATE OF WYOMING
ss.
COUNTY OF LINCOLN
DEBRA A. HANSEN NOTARY PUBLIC
COUNTY OF
LINCOLN
V_t F
MY COMMISSION EXPIRES
My Commission Expires: 3/24/03
Otto Kalan Trust \Affidavit of Distribution
STATE OF
WYOMING
Al l aket.
NOTARY PUBLIC
3
673
I, DOROTHY KALAN being first duly sworn, states that I am one of the affiants noted
above, that I have read the same, know the contents thereof, and that the statements contained therein
are true.
Subscribed and sworn before me this 2nd day of March 2000.
I A �Iaa uu ���r��mm 10500,010.0.
and Rule LOCAL FILE NUMBER 18-5534
DECEDENT
PARENTS
INFORMANT
CERTIFIER
REGISTRAR
CAUSE OF
DEATH
UGH -BVR
Form 12,
Rev. 12/98
1. NAME OF DECEDENT FIRST
MIDDLE' LAST
(al an
Otto
4. DATE OF BIRTH (Mo., Day, Yr.)
July 23, 1925
8a. PLACE I HOSPITAL (ohm me,: ax NapM y polyp I ALL OTHER LOCATIONS:
OF DEATH 1 Inpa
i I r'^7 -8. Nura Home 8. Rasklsnea (any)
(check ony I
one) 02. ER/Outpetlent D3. DOA I L- 1 7; Oewr (specify)
8c. CITY, TOWN, OR LOCATION OF DEATH
Salt Lake City
10. WAS DECEDENT
EVER IN THE U.S.
ARMED FORCES?
11111. Yes 2. No
13a. RESIDENCE STREET AND NUMBER
1427 5th West
13e. INSIDE CITY
LIMITS?
1. Yes
2. No
131. ZIP CODE
83101
5 AGE Last Birth
74':-
ry
11. MARITAL STAATUS
0 L Never Maried Q 3;. Wdenved
II 2. Married 0 4: Divorced
8d. COUNTY OF DEATH
Salt Lake
12a. DECEDENTS USUAL OCCUPATION (Give kind of work done
during most of working life. Do NOT ente, retired)
Business Owner
14. WAS DECEDENT OF HISPANIC ORIGIN?
(dyes; Speafr)
L] 1.Mekioan 2, Ciban
0 3. Puerto RIcan ,Q 4. Other (Specify)
1. Yes ■2. No
17. FATHER'S NAME (1,8 *410* .oG:
George Kalan
19. NAME, RELATIONSHIP AND MAILINQ ADDRESS OF INFORMANT'
Dorothy (Wlfe)�;1427 5th West Kemmerer, Wyoming 83101
20. METHOD OF DISPOSITION
1. Entombment❑ 2. Donation 3. Other
DISPOSInON `4. Burial 5. Cramationj 6 Removal
Dec. 20 1999
22 NAT�EO U
I 1 ,GL
25. DA E DECEASED WAS LAST I not Certified by medical examiner, was death reported to M.E.7 0 1. Yee a 2. No
ATTENDED BY CERTIFYING PHY,S IAN I(yes enter the date and hour reported.
191. CASE NO HR. MO _DAY __YEAR
n 27a. CERTIFIER
1Pt
1. CERTIFYING PHYSICIAN: To the bete of my knowledge, death occurred at the time, data, and place, and due to the cause(s) and manner as stated.
0 2. MEDICAL EXAMINER/LAW ENFORCEMENT OFFICIAL: On the bests of examination and/or Investigation, In my opinion, death occurred at the time date, piece and due to the
08800(1) andmNmer as stated:';
275. S NATURE AND TITLE. OF CERTIFIER
25 NAME AND ADDRESS OF PERSON WHO CERTIFIED THE CAUSE OF DEATH (them 31) (Type/Print)
ohr. W. o(.ar f.r'.M� /1'LQfiPi rs/ 32210, Ssdf 4 /ce C7f 6
29. REGISTRAR'S SIGNATU 300. DATE REGISTRAR NOTIFIED OF DEATH 30b. DATE FILED (Mo Day, Yr.)
eI (Mo., Day, W)
Dec. 22,1999 December 28, 1999
31. PART I. ENTER THE DISEASES J IES OR COMPLI TIDNSTHAT CAUSED THE DEATH. DO NOT ENTER THE MODE OF DYING, SUCH AS CARDIAC
OR RESPIRATORY AR SHOCK OR HEART FAILURE. LIST ONLY ONE CAUSE ON EACH LINE.
IMMEDIATE CAUSE (Final
disease or condition resulting
In death)
Sequentially list conditions, if
any, leading to Immediate
cause. Enter UNDERLYING
CAUSE (disease or injury that
Initiated events resulting In
death) LAST
a ;FY c e b
2L I k4'rn e ,�rllo��
'DU$'.Tb (QR AS A. CONSEQUENCE OF):
b.. LIr•,Y ic•( t'-/n i o ft
"DUE TO (OR AS A'.CONSEQ0 CE dF):
DUE TO (OR AS A CONSEQUENCE 00):
Approximate Interval
Between Onset and
Death.
r J
1..fet !CI Ow
PART II. Other Significant Condition() c9
but not resulting in the underlying cause given in Pall
34. MANNER OF DEATH
Sgt. Natural 0 2. Accident
03. Suicide 0 4. Homicide
5. Undeterminedf 6. Pending
If injured Investigation
Purposely or
Accidently
rt that
ddle,
Elementary completed)
s is a rue copy 'o a ce 'on a In ice. Is certified
under authority of section 26 -2 -22 of the Utah Code Annotated, 1953 As Amended.
do
O' Date Issued:
County Salt Lake
m
o Registrar
DEC 281999
L129807
ATE OF UTAH DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH
copy Is Issue
Barry E. Nangle
DIRECTOR OF VITAL RECORDS
By
STATE FILE NUMBER
086'7364
II 4 0 OF T.61
0 4 i \L
0141Uttlivtbntariki
VeN o ..re4 r 0 4 j l
2 g g 6 i
PG aaarr
.O F
6
b✓ i rT, j�;:
ce
TE OF UTAH
D EPARTM ENT OF H EA LT
WARNING: IT IS ILLEGAL TO DUPLICATE THIS COPY FOR OFFICIAL PURPOSES.
T ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATION 'YT