HomeMy WebLinkAbout975181STATE OF WYOMING
COUNTY OF LINCOLN
AFFIDAVIT FOR COLLECTION AND DISTRIBUTION OF
DECEDENT'S PERSONAL PROPERTY PURSUANT TO W.S. 2 -1 -201
SS.
975181 2/5/2014 9:25 AM
LINCOLN COUNTY FEES: $18.00 PAGE 1 OF 3
BOOK: 827 PAGE: 823 AFFIDAVIT
JEANNE WAGNER LINCOLN COUNTY CLERK
I
I, John C. Erickson, 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 sole distributee, as hereinafter set forth,
and that I make the following statements in connection therewith:
1. That Betty Jean Erickson aka Betty J. Erickson became deceased on December 31,
2013, in Salt Lake City, Salt Lake County, State of Utah; that said decedent was a
resident of Afton, Lincoln County, Wyoming, at the time of her death; that said decedent
was married at the time of her death to the undersigned; that said decedent died
intestate; that I am the surviving spouse and heir of the decedent; and that I am the sole
and only party entitled to the estate of the decedent in accordance with the laws of the
State of Wyoming.
2. That the value of the entire estate of said decedent, wherever located, does not exceed
$200,000.00.
3. That more than thirty (30) days have elapsed since the date of death of the decedent.
4. That no application for the appointment of a personal representative of said decedent is
pending or has been granted in any jurisdiction.
5. That the following named distributee is the sole and only party 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 distributee is entitled to payment or delivery of all
of decedent's property:
Name Relationship
John C. Erickson Spouse
1
I11I11II111111III1111111IIIlIH IIIIIIIII IIIIIIIII111111III1111111I
2013.
6. That among the assets owned by said decedent was the following:
Rock Springs National Bank Checking Account No. 11096930 in the name of
Betty J. Erickson.
All right, title, and interest in and to the above property should be transferred
to the undersigned.
7. That attached hereto and incorporated herein by this reference is a certified copy of the
death certificate for the decedent.
8. That the original of this affidavit is being filed of record in the office of the County Clerk
of Lincoln County, Wyoming, in compliance with W.S. 2- 1- 201(c), as amended.
EXECUTED as of the 3rd day of February, 2013.
Witness my hand and official seal.
GERALD L GOULDING NOTARY PUBLIC
County of State of
Lincoln Wyoming
My Commission Expires May 2, 2015
My commission expires: May 2, 2015.
2
John C. Ericks
Subscribed and sworn to before me by John C. Erickson, this 3rd day of February,
NOTARY PUBLIC
STATE OF UTAH
A- .5
1 1,
DECEDENT INFORMATION
Date of Death:
City of Death
Spouse's Name
Arnied,SerOlOes:
IndustrY/B64inisat..::
Residence:
'WtersNarne:
acility or A44reS%
INFORMANT INFORMATION
Name: John Clarence Erickson Relationship: Husband
Mailing Address: Box 1622, Afton, Wyoming 83110
1)ISFOSITIORINFORNIATION
Method of Disposition: Burial/Removal
Place of DiSposition: Fairvievy Cerrietery, Fairview, VVyoming
Date of Disposition: January 4, 2014
MEDICAL
Medical Professtonal Shawn M Smith MO 5121 Obttbriwood6t:',.IVIUrra Utah 84107
Subarachnoid Hemorrhage poset. 7 Days]
Du to (or as...a consequence of): Intracranial Aneurysm RupturelDnset7..Days]
Medtcal Exanliner:COntabted:: peifo -Manner /1)f. Death: Natural
gN.DMENT:Kl.STORy•
:Decernber:::31 :1013 Ti
Murray County of Death:
56 Date of Birth;
Poison,. Montana Sex:
No Marital Status:
John Clarence:Erickson Usual 0obupatiortAegiOn:al SuperviSbr
Wyorning•DePartrnent Ti-f cation: Associate Degree
Afton Wyoming Fathers Name .Ray..Downerq Frame
Hilda Bernice Shinkle Fe Hospital lnpatient
Iiiterrnmintain Medical Center
FONBRAL HOMBINFSIAMATION
Funeral Home jenkins-Soffe South Vatley.:
:Address: 1007 West South Jordan ParkWay,. South Jordan, Utah 84095
Funeral Direator .Justln M Ford
70,1 Jana 2014
TIFICATE OF;
State File Number 2013016703
Betty Jean Erickson
bateRegistered: December 31, 2013
::.:Pateliabed::::4anaark.1 2014:
06:25
Salt Lake
Vay:16i:::1957
Female..:
01/65:120141inrrate Cause f beathfr om CerebellarNemorrhage to Subarachnoid Hemorrhage
.......01408/2014 Immediate Interval from 022 to 007
..61166/201 4 IiiiinediatqAtitarva[kinit.fram Hours:lo
Additibriel:Ce00e 0.1)eatiftfrom AIO.Oh0.110:
01/06/2014 AdditiohilintetVat from 005 to (blank)
01108/2014 A6ditionalinteivay, .lnit YearSIO'..:(blank)
01/08/2014 Underlying Cause of Death from Cerebellar Hemorrhage to Intraoranial.Anearysm Rapture.
.....:::01/05i2014 UriderlykngInterval 007
*.........:01/0.W044.0.?0erik.ifitiintervatIPriit 0*/*•••..;
••••0V(18/1014:0OriditlOn:::70ontribatinOio::::Dealro6:01100nIO:..Cocaine;Uie tii:(blank):....:.:.'
Thisis an exact reproduction of the facts registeredin the Utah State of yital....qappitwarid Statistics
Senrity...leattaiitS0 thiSSOfficiattlecument inaudikIntagiskillorder, V&A images in t'40 cOloi010;•anitintaiiiio
OF T.tigaili, This document diSpla*theldatei*al and SiO natUre/oftheliten$tatRegiatrar and'if*CountAiiiiict:HealtlioffiCer.
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I 11 1 I 1111 III 1111111 tary L. dwards
anice L Houston
0A.1 Director/Health Officer 'i■%.■
State Registrar
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