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LINCOLN COUNTY FEES: $$18.00 PAGE 1 OF 3
BOOK: 833 PAGE: 778 AFFIDAVIT
JEANNE WAGNER, LINCOLN COUNTY CLERK
IIIII II IIII 111111 11 HIN 11 11111111 1111 II 111 III
AFFIDAVIT FOR DISTRIBUTION
OF DECEDENT'S PERSONAL PROPERTY
PURSUANT TO W.S. 2 -1 -201
STATE OF WYOMING
ss.
COUNTY OF LINCOLN
I, MARISELA HUMPHERYS, 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 ROBERT CLARK HUMPHERYS became deceased on June 16, 2012
in Pocatello, Bannock County, State of Idaho, and was a resident of Etna, Lincoln
County, State of Wyoming, at the time of his death; that said Decedent died intestate; that
said Decedent left Marisela Humpherys, as surviving spouse; that the sole and only
parties entitled to the estate of said Decedent are the distributees herei na`ter 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, wherever located, does
not exceed $2,000,000.00.
3. That more than thirty (30) days have elapsed since the caate 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 10 payment or
delivery of all of the Decedent's property:
Name Relationship
Marisela Humpherys Spouse
Rusty Humpherys Son
Timothy D. Humpherys Son
Mary Jo Ryan Daughter
Luke W. Lufkin Son
Joseph Lufkin Son
E.G.H., a minor Daughter
N.C.H., a minor Daughter
Affidavit for Distribution
Page 1 of 2
5. That among the assets owned by said decedent are the following to be
distributed to the surviving spouse, Marisela Humpherys:
2002 Jeep UTLP, VIN 1J4GW48S02C243510
2007 GMC PU, VIN 3GTEK 13Y77G504879
6. That an executed copy of this Affidavit is being presented :o the transfer
agent for the above listed asset in compliance with W.S. 2 -1 -201.
EXECUTED this 3 day of 2014.
MA'RISELA HUMPHERYS
Address: P.O. Box 5176
Etna, WY 83 1 18
STATE OF WYOMING
ss.
COUNTY OF LINCOLN
SUBSCRIBED AND SWORN to before me, a Notarial Officer, by MARISELA
HUMPHERYS this 2 c day of i,t- ri 2014.
CRYSTAL L. SLAUGHTER NOTARY PUBLIC
County of 3 State of
Lincoln o� Wyoming 1 j 'o' 4/,' t_ 7 1 I
My Commission Expires February 3, 2018
NOTARY PUBLIC
My Commission Expires: /i•'
Affidavit for Distribution
Page 2 of 2
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r. CERTIFICATION OF VITAL RECORD 4 s
V'! II t1 f f '1
STATE OF IDAHO
f
IDAHO DEPARTMENT OF HEALTH AND WELFARE
BUREAU OF VITAL RECORDS AND HEALTH STATISTICS
State of Idaho
j ONLY Co L `yuD V CERTIFICATE OF DEATH
E v {X]a MENTOraE.l ,I 1 K■J Sri z r o e s Loc Reg. No
I Ir DECEDENT •1.DECEDENT'S LEGAL NAME (Include AKA's g any) (Frst, Middle Last. Suffix) 2. SEX 3. SOCIA- SECUTITY NUMBER 1A\
4 PE DR ROBERT CLARK HUMPHREYS MALE 520 2.34 ;4
PRINTrN y
w-
4a, AGE-Lest Birthday 4b.UNOER I YEAR 4C. UNDER I DAY 5. DATE OF BIRTH (Mo/Dey/yr) 8. BIRTIIPLACE(Cdy and Stale. 1 ardor), K .crater Country)
PERMANENT 0 62 Months Da ye Hours Minutes
aIACK INN
05/01/1950 AFTON, WYOMING "II(Zbb))y]]/��� r Jr
OO NOT USE (years)
a SID R O
FELr nP PEN 7a. RESIDENCE -STATE OR FOREIGN COUNTRY 75. COUNTY 7c. CITY OR TOWN
FOR o WYOMING LINCOLN ETNA
INSrRUCT10N5 O 7d, STREET AND NUMBER 7e. APT. NO. 7f. ZIP CODE g. INSIDE CITY
SEE 11%7
CITY 855080005 105762 HIGHWAY 89 83118 Yes No
6. MARITAL STATUS AT TIME OF DEATH
LL 9. SURVIVING SPOUSE'S NAME (Ilwife, gob. maiden mane)
7 0 Marred 0 Marred, but separated 0 Widowed 0 Dammed 0 Never marned 0 Unknown MARISELA ISABEL MARTINEZ
PARENTS Zr' 10. EVER IN U.S. 11a. FATHER'S NAME (First. Middle, Laser Suffix) 11 b. BIRTHPLACE (Stale Ternlo or Foreign Country) I
3 ARMED
i FORCES? DEAN G. HUMPHERYS WYOMING t
0 Yes 12a. MOTHER'S MAIDEN NAME (Fast. Middle. Last, Suffix) 12b. BIRTHPLACE (Stale ito y or Foreign Country) 4 �.T
v d
E ®N 0
o NEVA CLARK WYOMING
1` INF ORMANT U 138. INFORMANT'S NAME (Type or print.) 135. RELATIONSHIP TO DECEDENT 130. MAILING ADDRESS (Street and Number City, SI: '0. Zip Code)
F MARISELA HUMPHREYS SPOUSE P.O. BOX 5176 ETNA, WY 83118 1 IV
Z
Q ®o n i l dP DISPOSITION Entombment 5 ETNA CEMETERY N and address of cemetery
a HAWKER COMPLETE ADDRE 1S
HO +IE oF FUNERAL FACILITY
V B Cremation crematory, M place) f
Ce
Removal pmlo 132 SOUTH SHILLING AI7 NU'_
Other (Specify) ETNA, WYOMING 83118 BLACKFOOT, IDAHO 83..21
'17e. SIGNATURE OF FUNERAL SERVICE LICENSEE OR PERSON ACTING AS SUCH 17b. LICENSE NUMBER (Of licensee) 18' DUE r0 CAL SF CONTACTED
ELECTRONICALLY FILED: KEVIN T. DIETRICH M0748 C) Yes ®No
PLACE OF PLACE OF DEATH (19 -22)
DEATH 19a. IF DEATH OCCURRED IN A HOSPITAL 190 IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
l y73 10 Inpatient 2 DER/Outpatient 3000A 40H pce facility 5 Nursing home/Longlm care leceity 60Decedene's home 70 Other (Specif)'
1 20.FACILITY NAME (11 gg3 (acilily g setae/ end number) 21. CITY, TOWN, OR LOCATION OF DEATH, AND ZIP CODE 22. COUNTY OF DEATH
PORTNEUF MEDICAL CENTER POCATELLO, ID 83201 BANNOCK
i DA m
TE O 23. DATE OF DEATH (Mo/DayTY (Spell month) 24. TIME OF DEATH 25. DATE PRONOUNCED DEAD (Spell onl 28.' IME PRONOUNCED DEAD
DEATH (249,) (249,1
June 16,2012 17:15 June 16, 2012 17:15
CAUSE OF 27. CAUSE OF DEATH y�"v:,
DEATH PART I. Enter the ;ham 01 e9enli -diseases. complic 1 th s lnal directly caused the dea DO NOT enter terminal events such as cardiac Approximate Interval I]\
1 arrest, respiratory arrest or ventricular fibrillation without howing the etiology. DO NOT ABBREVIATE. Enter only one cause one line. Onset to Death A
y IMMEDIATE CAUSE (Final SUDDEN CARDIAC DEATH ACUTE
tp disease or danait do ■I tJ
reselling in death) DUE TO (or as a consequence of): y
-C Sequentially hstcanddion5, b UNKNOWN
d it any, leading to the cause DUE TO (or as a consequence of):
it
p listed on line a. Enter the
UNDERLYING CAUSE p
o resulting n aealn) n LAST disease or lo
m that metaled the events
'o DUE TO for as a consequence a F�
C
j
d..
Jr r PART II. Enter ether significant 50nd4)0ns cnntnbulno t0 deal/ but not resulting m the underlying cause given in Part I 28e. WAS AN AUTOPSY 28b. M ERE AUTOPSY FINDINGS
C PERFORMED? A 'AILABLE TO COMPLETE 1
Iyy1 y TIE CAUSE OF DEATH? E
i 29. DID TOBACCO USE 30. IF FEMALE (Aged 1054): Yes No Yes 0 No /4
O CONTRIBUTE TO DEATH? 0 Not pregnant sethin past year Not pregnant. but pregnant 43 days 31. MANNER OF DEATII �I
d ry
Yes Probably Pregnant at time of death t.0 1 year before death
Natural Ho ude
E pregnant pregnant pas Accident. Pe i9.n Investi t I
O No ®unknown within ❑Not pregnant., loaf e t Unknown i 1 within the t g ga ion
n az days al deg h rear sa tae Coda not be dale mred
I TEMS 32ae 32. DATE OF INJURY (MO/Dey/Yr) 33. TIME OF INJURY 74. PLACE OF INJURY (Decedent's home. farm, slreel, constructions 1+ 35. INJURY AT WORK? 3
I TO BE USED IY (Spell month) (2471) nursing home, re la ant, forest, etc.) sy/�{
FOR EXTERNAL W Yes No
'S`e
CAUSES ONLY
U. 1i
38. LOCATION OF INJURY:
(CORONER) Stale City/ Town or County Zip Code 9 9
d
W i q
Street and Number or Location Apar mein N rmcer
dh
h 3 37. DESCRIBE HOW INJURY OCCURRED. IF TRANSPORTATION INJURY, STATE THE TYPES(S) OF VEHICLE(S) INVOLVED (Automobile pickup molar[ /ale. ATV. bicycle. etc) 1 X
SPECIFY WHICH VEHICLE DECEDENT OCCUPIED, If applicable 1
0 TRANSPORTATION 388. WAS DECEDENT: Drawer/Operator 0 Passenger 385. WHAT SAFETY DEVICES /S/ 01D DECEDENT USE/EMPLOY'
INJURY ONLY Pedestna Other (Specify) Seal ben Child safety seat Helmet 1.1 bag None Unknown
CERTIFIER 39a. CERTIFIER (Check only one. based on 000ial capacity for Inns certificate) 391. LICEE 51 NUMBER f
f PHYSICIAN PHYSICIAN ASSISTANT ADVANCED PRACTICE PROFESSIONAL NURSE M -0E 795
IF DEA WAS To the best of my knowledge. death occurred at the lime, date, and place, and due to the natural cause(s) /manner staled.
00510 06055 'l
MAN NATURAL CORONER
C On the basis or examination and /or investigalron, 1111119 opinion, death occurred at Ire bme. dale, and place, and due to the cause(s) 39,, DATE SIGNED y
THE CORONER
and manner sealed. E 25 2012 19
i Hal Slg rare and Tine of Certifier 1 DAVID M. GONZALEZ, M.D. n M DD YYYY
COMPLETE AND
SIGN THE 39d. NAME, ADDRESS, AND ZIP CODE OF CERTIFIER (Type or pin!)
CERTIFICATE
DAVID M. GONZALEZ, 777 HOSPITAL WAY POCATELLO, ID 83201
:Will i :7.1 40a. REGISTRAR'S SIGNATURE 4111 DATE SIGNED t o
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M
DD YYYY
"1111111 1t l q This is a true and correct reproduction of the document officially registered and placed \\\IIL91,,, l li
�A P on file with the IDAHO BUREAU OF VITAL RECORDS AND HEALTH STATISTICS. Dimly 1
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;/.3 r j r DATE ISSUED. F �.CJ J r�SQ,'loZ /441414 1 Arrr,,,LLLLLL D J'VAL VALI L
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1 I JAMES B. AYDELO'1 TE A L t LIDVA
i� 1,9<, app g This copy not Id unless prepared on engraved border u L L 'OVA 8 (p ir'S, displaying state seal and s gnature of the Registrar- STATE REGISTRAR l°v :t.,,,,;,;:,.. .1, 'V0L
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