HomeMy WebLinkAbout976309BAN -I EST,
NOTICE TO BANK: MUST BE FILED WITH COUNTY CLERK AND BANK MUST RECEIVE A CERTIFIED COPY
PRIOR TO ANY DISTRIBUTION OF ASSETS.
I/We [Enter name(s)] /f,' Pcy-, •,Sf- Iy R r. P r( fi t (individually
and jointly "Affiant whose address(es) is /are: (Attach additional sheets as needed)
I>ti`
mewl. i 11,. a $3110
declare to Bank of the West "Bank that the following is true and correct:
1. (Name of Deceased) ZC.' .2,r �ii/
f1� m e.t "e c
on (Date) 5////1
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; gChild
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: ?4 j
(a) Funds on deposit in the aggregate sum of B 8,i S�r�I�-� •tt fA j lu w tr d S, ;•,ty /V v �b� eAt q lays
7e9',
Branch Name
f,, rower_ e�iv/1rUirl� /Ztr 47/ 7* 9 CI
(c) The decedent's interest in: (Describe)
AFFIDAVIT UNDER PENALTY OF PERJURY FOR RELEASE OF 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)
County of State of D V p el,
in the following accounts:
(b) Personal property situated in safe deposit box or vault no.
City /State Account No. Amount
5? /,L 5
(the "decedent died in the City of
or held in safekeeping at this branch; (Enter
Branch Name and State)
976309 4/25/2014 3:36 PM
LINCOLN COUNTY FEES: $0.00 PAGE
BOOK: 831 PAGE: 179 AFFIDAVIT
JEANNE WAGNER, LINCOLN COUNTY CLERK
111111111111111111113 (1111 11111 1111 it 1 III 1111 1111
Page 1 of 2 030 -05180 (Rev. 07/11)
Name and Address
Relationship to Decedent
Proportion Due Each Distributee
�t/
1) Cllr /,'4 4,, :r
is•
0
(z z 5f
2 Ai r,*-, 2A e 0I If 4 5 l'71/
t'r, of
33:1/7
l�
(kr# rn tJa t/ iis
rai e .Or li0", 0 afah
.si.a6
3 ,e6 Z (s'e1 113/7
3 r`A
bkliyFkk r
3c f ILO Si—
b 1c(rAttt(I /(J 13 1I (0
4)
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:
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(i! irS 20 4 in the City of 71/11/14,-e
State of
MUST BE EX CUTED BY ALL DISTRIBUTEES.
Ne
STATE OF W 90 1 l
COUNTY OF I Y, i
On ��1'` t 20 befo e me the undersigned, a Notary Public in and for said State, personally
yyryry p 1
appeared 1) r i l"T, tJ O 1..I /)I, \Il I 1 tl )1k qj 1 personally
known to me (or proved to 4 on the basis ofJsaiisfactory evidence) to be the person(s) wRose 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 han
Signature:
Affidavit Small Estate Wyoming
Page 2 of 2
Si at
n se t j Aii WI)
April Brunskl Notary Public
S el)
County of
Uncoin
I'f; Commission Expires
�1, 0305180 (Rev. 07/11)
�,.a�••.�a- ra�r`� "Q"�"�v G` v`.+ W`+ vs�t +J��'+a£+r,J*t5'CraaG>aw4�x'
Signature
S ignature
Name and Address
Relationship to Decedent
Proportion Due Each Distributee
1) jJ• ev ,9-, e�
151—
/79/9 1trV t. 1
2) Yr ie. CA rte& 'c,p 4
2,t d
5 L 1
6 7 5 /A (4`oi 7 c'✓e� f1 ('p
in Sint /70,1 0/),(,:, 10
A' v
3
ba a
cf //0,/ 5.`-- v
b;4 14,y, 4 4/ <5 3// 6
4)
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:
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 f 1 `4 20 41, in the City of G`I
State of T C 91 7( s''"0
Affidavit
Page 2
MUST BE EXECUTED BY ALL DISTRIBUTEES.
/Signature
Signature
STATE OF CC�C i D
COUNTY OF
V t,- Cc
Signature
Signature
On p' I 5 20 LI before me, the undersigned, a Notary Public in and for said State, personally
jj
appeared a G 09,o 2,0 personally
known to ine (r proved to me on the basis of satisfa ory d 'dente) 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.
(Seal) JOSH 'W HIGGS
Notary Public
State of Colorado
Notary ID 20134043599
M Commission E fires Jul 25, 2017
WITNESS my h and offs ial seal.
Signature:
Esta yoming
030 -05180 (Rev. 07/11)
Decedent: State File Number: 2014-00
Narne: William Lee. Popp
Denier. Male Social Security Number:
Date of Birth: July 03, 1945 Age at the Time of Death: 68 years
Date and Place of Death:
Date of Death: March 01, 2014 County of Death: Ltncotn
City of Death: Kemmerer
Location: Foothill Hwy. 189 310 Sp#3
Additional' Decedenttnfarmatlon:
Pia4e of Birth: Lenard, Kansas
Residence: Kemmerer; Wyoming
'Marital Status Divorced
Armed Forces: Yes
tlaroe of Father: Henry Po 1
!Y pR
Name of Mather: Rosa Mae Relfschneider
Informant: William Lee Popp, Jr. Relationship: Son
nisposttion:
Method of Disposition: 'Donation
Place of Disposition: University of Utah Organ Donation, Salt Lake City, Utah
Funeral Home orfacility
Facility: Ball Family Chapel; Evanston, Wyoming
Cause of Death:
The lmri edlate cause is listed On the first line followed by any underlying causes. Interval.:
1 (a) Lung Cancer 1 Month
(b) Smoking (Tobacco Abuse) Decades
r
Other Significant
Conditions:
'Manner of Death:
STATE OF WYOMING
Certifier.
Type: Physician
Name: George Krell, M.D.
Address: PO Box 390, Kemmerer, Wyoming, 83
This is a true certification of the document on file in the office of Vital
Statistics Services, Cheyenne, Wyoming,
DATE ISSUED: Friday, March 14, 201;4
This copy is not valid pales prepared on paper with an cograved border.
DEPARTMENT OF i EALTH,
CERTIFICATE OF DEATH