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Home My WebLink About977195STATE OF PENNSYLVANIA COUNTY OF WESTMORELAND 977195 6/27/2014 11:52 AM LINCOLN COUNTY FEES: $30.00 PAGE 1 OF 6 BOOK: 834 PAGE: 827 AFFIDAVIT JEANNE WAGNER, LINCOLN COUNTY CLERK 1111111il1i1111101IIIIIi III 0111111111111111111111111111111111111 11111111 ss. AFFIDAVIT OF SURVIVORSHIP I, MATTHEW SCOTT MILLER, being first duly sworn, on oath depose and state that I make this Affidavit pursuant to W.S. 2 -9 -102, on behalf of myself, as a distributee, as hereinafter set forth, that I make the following statements in connection therewith: 1. I am the Affiant herein and am of adult age. 2. On July 29, 2010, SUSAN MARY MILLER passed away on July 29, 2010, in Sandy, Clearfield County, State of Pennsylvania, as is evidenced by the Certificate of Death attached hereto as Exhibit "A" and incorporated herein by this reference. 3. Decedent left Clair E. Miller as her surviving spouse; and Kathleen Dawn Shugars, Matthew Scott Miller, and Melissa Ann Johnston as surviving children. 4. At the time of Susan Mary Miller's death, she and her spouse, Clair E. Miller, owned certain items of personal property located at 245 Cottonwood Lane, Smoot, County of Lincoln, State of Wyoming, and more particularly described as follows: a. 2008 Dodge PU, VIN 1D7HW58N18S562431 b. 1992 PROCR BOAT, TAB NO. 342255 c. Boat, WY- 1985BB, Hull No. MPDT1206E292 5. At the time of Susan M. Miller's death, personal property passed to her surviving spouse, Clair E. Miller. 6. On July 1, 2013, Mr. Clair E. Miller passed away in Afton, Lincoln County, Wyoming, as is evidenced by the Certificate of Death attached hereto as "Exhibit B" and incorporated herein by this reference. 7. Decedent left Kathleen Dawn Shugars, Matthew Scott Miller, and Melissa Ann Johnston as surviving children. In the Estate of Clair E. Miller, Probate No. PR- 2013 -53 -DC Affidavit of Survivorship re: Vehicles (Matthew Scott Miller) 1 of 4 8. The distributees have agreed that Matthew Scott Miller shall receive the listed vehicles belonging to Susan M. Miller and Clair E. Miller, as evidenced by the Certificates signed below. 9. 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 -9 -102. DATED this t day of STATE OF C� ss. I :AZ.)1 MATTHEWSC, m o o v :4/ SUBSCRIBED AND SWORN to before me, a Notarial Officer, by MATTHEW SCOTT MILLER this day of 2014. My Commission Expires: I JC� 1 2014. In the Estate of Clair E. Miller, Probate No. PR- 2013 -53 -DC Affidavit of Survivorship re: Vehicles (Matthew Scott Miller) 2 of 4 CERTIFICATE OF APPROVAL The undersigned, KATHLEEN DAWN SHUGARS, daughter of Susan Mary Miller and Clair E. Miller, hereby approves the release of the three listed vehicles to Matthew Scott Miller from said estate. DATED this /A day of STATE OF Wr r COUNTY OFJI/� TRACY MATTHEWS NOTARY PUBLIC County of Lincoln State of Wyoming My Commission Expires October 22, 2017 My Commission Expires: The foregoing was acknowledged before me, a Notarial ffic by KATHLEEN D_WN SHUGARS, who personally appeared before me this day of 2014. Witness my hand and official seal. s 2014. KATHLEEN i A SHUGARS In the Estate of Clair E. Miller, Probate No. PR- 2013 -53 -DC Affidavit of Survivorship re: Vehicles (Matthew Scott Miller) 3 of 4 CERTIFICATE OF APPROVAL The undersigned, MELISSA ANN JOHNSTON daughter of Susan Mary Miller and Clair E. Miller, hereby approves the release of the three listed vehicles to Matthew Scott Miller from said estate. DATED this 1 L j day of J G�1 2014. STATE OF vis■ 1 vow CPS COUNTY OF Z-4l ex Witness my hand and official seal. My Commission Expires: T-62-17 ss. The foregoing was acknowledged before me, a Notarial Officer, by MELISSA ANN JOHNSTON, who personally appeared before me this 1 `1 day of 2014. In the Estate of Clair E. Miller, Probate No. PR- 2013 -53 -DC Affidavit of Survivorship re: Vehicles (Matthew Scott Miller) 4 of 4 COMMONWEALTH OF PENNSYLVANIA Notarial Seal Susan M. Rothbauer, Notary Public Cranberry Twp., Butler County My Commission Expires Aug. 6, 2017 1. Name of Decedent (First, middle, last, sutra) Susan mare miller 2. Sex r{mn le� 3. Social Security Number 4. e of De (Mon th, day, year) a9 ado 5. Age (Last Birthday) Q 68 Yrs. Under Under 1 day 6. Dale ol Birth (Month, day, year) 7. Birthplace (City and stale or foreign country) Ba. Place of Death (Check only one) months Days Hew Mamas cau n, Feb1�cc•1 I-1Q ya P11)sbi i h PR Hosplah, ❑Inpatient ❑ER!Outpatient 0 DOA Other. Nursing Home 3 Residence ❑Other•Specify: Bb. County of Death I �1 e(� Be Gily; Bmv-Twp. al Death 5 (1 Ll Bd. Fealty Name (If nol institution, give street and number) L D 1 o LI 9 7 .1 k easy re 1 a rte-• C cqd 9. Was Decedent of Hispanic Origin ig No Yes (II yes, specify Cuban, Mexican, Puerto Rican, etc.) 10. Race: American Indian, Black, White, etc. (Specify) White. 11. Decedents Usual Occupation 16indof work done dudggmost olworking De. 6o not state retired) 12, Was Decedent ever in the U.S.Anned Forces? oyes �Na 13. Decedent's Educaton (Speciyonly highest grade comp eled) I4. Madlal Status: Married, Never Manied, Widowed, Divorced (Specify) Married 15. Surviving Spouse (II %ire, give maiden name) Clair E. miller IOnd of Work TPAnc�rs Aide ICuLd of Business /Industry Education Elemental/ (0-12) a College (1-4 or 5 16. Decedents Meng Address (Street l et, 1 ctyl loom, late, zip code) (p26 Treasure Lite Q a �j DUBOIS PII 15$01 Actual Residence 17a. Stale PA 1 Live in a Decedent 17c. Yes, Decedent Lived in San. d Twp. y 175. County C ieal"'T'(P�I .Uh• Tdwnshi 17d. No.DecedenlLivedvdlNn Adual Lids of City/ Bore 18. Father's Name (First, middle, Iasi, sutra) Charles R. Gre'ened 19. Mother's Name (First, middle, maiden surname) rear P 'Cassidy 20a. Womtanrs Name (Type lPrint) CI Air E. rylili 206. Informant'sMafingA Peet, a1yl town, stale, npcode) 1p8'6 treasure lake DuBois PA 158oi 21e. Method of Dispositon X I Burial Removal from Slate l❑ CH Speciy: ❑Cremation ❑DmmGon Was Cremation or Donation Authorized by Medical Examiner/ Conner? Yes r__, No l 21b. Date of Disposition (Month, day, year) n U 3, A I D 21c. Place olDisposeion (Name of cemetery, crematory or other place) C. i u r y,+ f p r� y P C erl e 21d .LocaDon(Qly!town, slate, zip code) Lai I robe Pa 22a e d Funeral ivice e (or cling f l �I o 22b. License Number FD0 I4g01 22c. Name and Address of FacEy Goble ronlck.ulkarul Home II S. Main St. DuBois PA 15801 Complete Items 23aa only when ced:ying physidaels o ce de cause oldeat, 23a. To the best el my edge, death acamed al the 1me, dal and place stated (Signature and title) 23b. License Number 2 Date Signed (Month, day, year) l Cl e2 9 dole) Items 24.26 must be completed by person who pratamcesdeath. 24. Tune ol Death y' 7c) v M 25. D Pron Dead (Month, day, year) '1 CV i'1 Q /0 C'� 7 CJI 26. Was Case Referred to Medical Examiner Corone fd Reason Other than Cremation w Donation? T es Na CAUSE OF DEATH (See Instruction nd exerlfp es) Ilem27. Part h Enter the chain ol events dseases, injuries, or emigrations that derectycaus d the d DONUT temdnal events such ascardiacanesL Approximate INervat• Onset to Death Pad I Enter other ;;igniroanl [WHIMS contauli g to death, 28. Did Tobacco Use Contribute to Death? but not resulting in the underlying cause given inPeril Yes 0 Probably No Unknown respiratory arrest, or ventricular fibrillation a llhoul showing the etiology. List only one cause on each lne. IMMEDIATE CAUSE resting in cat6L p arredrnN) a hl .Q.:(1) Q h J y s P V 29.II Female: Due to asa consequence oQ: Seeqquuenntt'aaB8yyEdcenddans,Dany, b, C,h Q [r1 LYt�y [eadvg ILoLAs Not pregnant ithinpastyear Pregnant al lime aldeath els1ausebstedonlnea Enter hire UNDERLYING CAUSE Due to (or as a consequedce of): sea ts se es or u0in fiju g m rylhdealalh)tAST. intialedthe c. �den r /a I e 10 I)h Q t-r1 y 1 Not pregnan4 but pregnant within 42 days of death Due to (or as a consequence of): d. Nal pregnant but pregnant 43'days to 1 year before death Unknown it pregnant within the past year 30a. Was an Autopsy Performed? ❑Yes El No 30b. Were Autopsy Findings Available Prior to Completion of Cause of Death? ❑Yes No 31. Manner of Death Natural Homicide 32a. Dale of Injury (Month, day, year) 325. Desaebe Ho Injury Occurred 32c. Place of In ury: Horne, Fano, Street Factory, Office Buking,etc. Accident Pending Investigation Suicide Could Nat he Dele Mned 32d. Tune of injury M. 32e. Injury al Work? yes No 321. If Transportation Injury (Spedy) Driver Operator Passenger ❑Pedestrian ❑0ter• 32g. Location of Injury (Street, city! town, stale) 33a. CerEer (check only we) Certifying physician (Physician cell* cause of death when another physician has pronounced death and completed Item 23) To the best of my knowledge, death occurred due to the cause(s) and manner as slated_ Pronouncing and certifying physician (Physician both pronouncing death and certifying to cause of death) To the best of my knowledge, death occurred at the time, date, and place, and due to the cause(s) and manner as slated_ Medical Examiner) Coroner �o1I On the basis of examination and or investigation, in my opinion, death obcunedel the lime, dale, and place, and due to the cause(s) and manner as stated_ M•J 33b. Title ol r UPI() Q 1 4 �I License Number Dale sgggppped (4_,0-/ (Month, day, year. „Q 34 ame and Address rson%aCompleledCaoseol Death (Item Type 1 P d M sl.,61.wcr J n 1 d.�r% 2 j( -uQ1 gQn2 QOCIL+mn.h 1.6 161. Signature and D' 'd �'r 1 I D 1 1 1 i l 36. Dale Filed (Month, day, year) 0 /i /)CJ REV 11/2006 1 PRINT IN MANENT r56 INK ce cc W This is to certify that this is a true copy of the record which is on file in the Pennsylvania Department of Health, in accordance with the Vital Statistics Law of 1953, as amended. WARNING: It is illegal to duplicate this copy by photostat or photograph. 5703199 No. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS CORONER'S CERTIFICATE OF DEATH (See instructions and examples on reverse) 1"1141,1AR1 a a. STATE FILE NUMBER Linda A. Caniglia State Registrar AUG 112010 Date