HomeMy WebLinkAbout977354STATE OF PENNSYLVANIA
COUNTY OF WESTMORELAND
977354 7/8/2014 9:47 AM
LINCOLN COUNTY FEES: $27.00 PAGE 1 OF 6
BOOK: 835 PAGE: 718 AFFIDAVIT
JEANNE WAGNER, LINCOLN COUNTY CLERK
IIIIII1IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIll IIII IIIIIIIIIII IIIIIIIIII IIIIIII
sso
AFFIDAVIT OF SURVIVORSHIP
I, KATHLEEN DAWN SHUGARS, 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. 1994 HI LO HSE, VIN 1HOFCAR26RB017172
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 (Kathleen Dawn Shugars)
1 of 4
8. The distributees have agreed that Kathleen Dawn Shugars shall receive the
listed vehicle 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.
jj
DATED this day of
TRACY MATTHEWS NOTARY PUBLIC
County of �"s� !ato of
Lincoln 0.`'3, X /�/Zf �n� -ring
My Commission Expires vcicbe• :.2, 2017'
My Commission Expires: 1 04
2014.
KATHLEE R AWN HUGARS
ss.
SUBSCRIBED A J WORN to before me, a Notarial Officer, by KATHLEEN
DAWN SHUGARS this day of 2014.
UBLIC
In the Estate of Clair E. Miller, Probate No. PR- 2013 -53 -DC
Affidavit of Survivorship re: Vehicles (Kathleen Dawn Shugars)
2 of 4
CERTIFICATE OF APPROVAL
The undersigned, MATTHEW SCOTT MILLER, son of Susan Mary Miller and
Clair E. Miller, hereby approves the release of the 1994 HI LO HSE to Kathleen Dawn
Shugars from said estate.
DATED this 3 day of Lu L 2014.
STATE OF \L so C�
G� ss.
Cgtik OF
The foregoing was acknowledged before me, a Notarial Officer, by MATTHEW
COTT MILLER, who personally appeared before me this l5 day of
2014.
Witness my hand and official seal.
My Commission Expires:
-ao —s1.—(
MATTH W OTT LLER
OF
ao
®de9 Pdlli lt1t 0
In the Estate of Clair E. Miller, Probate No. PR- 2013 -53 -DC
Affidavit of Survivorship re: Vehicles (Kathleen Dawn Shugars)
3 of 4
c—L 0 c 4
LIC
CERTIFICATE OF APPROVAL
The undersigned, MELISSA ANN JOHNSTON daughter of Susan Mary Miller
and Clair E. Miller, hereby approves the release of the 1994 HI LO HSE to Kathleen
Dawn Shugars from said estate.
DATED this L/ day of J L[ 2014.
STATE OF M4 k [&r
COUNTY OF f z
Witness my hand and official seal.
My Commission Expires:
/6744 1/"
ME ISSA ANN JOHNSTON
ss.
The foregoing was acknowledged before me, a Notarial Officer, by MELISSA
ANN JOHNSTON, who personally appeared before me this 1 day of
,17).-V1 e, 2014.
111 the Estate of Clair E. Miller, Probate No. PR- 2013 -53 -DC
Affidavit of Survivorship re: Vehicles (Kathleen Dawn Shugars)
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 d Decedent (Rd. raid*.lasL sulix)
Susa 1 111art� Tiller
2. Sex
rtmaii
3. Social lSe Number
4. a of Dap (Mont, day, year)
lv 9q o�C7 /o
Q 5. Age (IasiBWday)
F a
o Y s.
Under al
Under lday
6. Dale o1Bulb(Moai year)
7, Bidhelace (Cnyandstaleorforegnmwby)
Be, Place ofDead (Cheek cot /are) (((fff d
moron
Days
Maus
maw
Feb a9 I q y a
n
Pt, ttsbu r h y PR
Hospilat
Inpalla I ER I Outpatient 00A
Mon
Nursing Nome g Resldanea ❑Other Spec*
Z Bb. County oI Death
i N
0Aeck VI
Be.O6renv,•Twp. clDeath
Sand
ed. Facility Name (II n d N s e N i a t ghe shad art amrbafi
1oLl97 /Qea. sort �14Fr
S. Was Decoded d lTdpanlc0d91n? m a No Yes
yes apedy Cuban,
MexJea,Pued0Rkan ote)
R a c e
(SPedM
white.
11,Deceden'sUsualOmpafdn(1 otworkdone udngmossofwu? rd state Mod)
12 Was Decoded ever In the
U.S.AnnedForces?
Dios r ANs
13. Decedent's Education (Seedyordy Welled grade completed)
14. MantelSalua Married, Mar Married,
Mowed, 0lmrced
Married.
IS, SuNMng Spouse plwlla gin maiden name)
Clair E cop
in Mod el Wak
W T neiVIS Aide
d&chessl uslry
F uc a i on
Elemenle /Secondary(0.12)
is
College
0 16, Decedent's MINAddress(Srodciyltown, tale,apcadh)
0 Tr as 1 r r 1! n
i u6o►s ►S
Decedent's PA Did Deco and
A 17a,Stele PA n w 17c Yea, Decedent UMIn Sand Y Tap
p
1m' ey Clear•P(e1d 17d❑ No, Decedent iNednildn
Actual limos of City/ Boo
18. Facets Nacre (Roll MO, lag sulfa)
Charles R. Greene,
I9. MdAer's Name (Rust, middle, maiden surname)
man. Pr. .Cassidy
RM. Inlarmenl's Name (TypelPM)
air E. miner
23b. lnlmrunl' s Mating ABO /ss Prod, dy Ada stale, 1pcede)
(p8'6 Treasure _1.Ke Ou6oLS PA 158o1
0 21e,MelhodolDisposition
co Build 6 Wj e Remorelhem Sate
m Ol Spe
❑C ❑Doren
byMtdulExemrwr
by d ecal on Bonito aaroAsdw7 Authorized Yes No
21b .OAelDisposkiorsU4mthday,year)
rl 01
Au 3 9310
2l Plate oDisposilim (Named cemetery, aematory
�ir Paul y •/ykyy
S1 Li LiG11IG G4
adhaplace)
1
21dLocatm(Cdy /lave, stale, zip add
Latrobe PA-
N 22a l el Funeral noon (or divas 9091) 1...1)
Q� L! /7?n 04.)
22b. license N tuber
FDO 4a�1
4� J
22c. Name and Address oI Fad81
Coble Boiron�ck fur J No me a S. Main S1. DuBois PA 15801
00 Complete Ilers23ator2/ when C009rg
physban
2 r*caaae s e ddgl available el Bme oldeed so
0e a01 dA9U
23a.To the bed dmy edge, deathamandetMe She. dale and place sbled. Ana 9r991111 Old
2311. License Number
2 Date Signed (Mont, day, yser)
"I Li rg 9 n t 0
Z U
c i
whopmmunmsdeeh
a
24. Tune of Death
y' o P M
25.
I
P Dead(Mdagyat)
(Mont,
26. Was C098RelerredloMadicalExordnm /Coronoto
Tes ❑No
Reason 00terlhanCremeOonorDau6on7
CAUSE OF DEATH (SeoInstruction
Item 27. Part I: Enter ne alley= 6seases, by VAas ,oroomp&allons- Mal drady caused the
resplratay and, or vemrkdar%Galion without shodng be etiology, List ody ono cede on
IMMEDIATECAUSE(1Flne Meese or
cool* resmhgMonth) a. Qm0 p; 5
L
J
nd wog es) s ApproslmateWent
0ONO}} agrderNmenal warm such as canine arrest, Onset toDmO
each he.
Pad Eder other sigile lmMie'onsmnlidmarodaelh
but not resulting In the =Whim 00usopheninPenL
O D
26, DOTdiaaoUsaCanNbNetoOeath7
Yea ❑Robeby
1:1 No ElUdmm
29.IIF
NolprepnenlvAWnpazlyas
Pavwmel6maoldaem
0
ofdealb
MIprapnant, bul prepare 43 days loIyear
bean Oaed
UrdasormE witin the pasl yam
Dog am
Due to es a=sequence of): s Sequnos3any, b ,n f C.' 0 rr Ca 1 l.. e 1) Lt(s9
leading to UMecauseWedoEnoa.
L o
z Ow arasecon
F EnterMheUNDERLYINGCAUSE sequence o9:
w (dteeseark�du7n4eamral the d,
et model )LAST,
OA e 6 i0 ry yo pz i
0
a Dueto(or asemnsequence op:
o d,
w
30a. Was enAMOpsy
,4 Performed?
0
❑Yes El No
30b,WeilAdopsyfrod+gs
Avails* Prior to Compielbn
wooed Oadh7
Yes NO
31. Manner
Natural Waite
Accident ❑Pendingdmesagaemn
Et Suicide ❑Colk Not beDetermined
323. Dale d Injury (Month, day, year)
F 32b.Desai0,11owlnleryOcamed
32e. Plea dlnlu7• km. Fan, 01edFoolery,
e. (S'099
Ofik Bu3&ng al
329.TireoINjury
M.
32e.InjuryeIWorld
❑yes 0 N
371.BTrenspatatimlryury a',)
❑DiNerlOperator ❑Passenger ❑Pedesden
❑Dma•spedry:
32g Lace1bn dwary (greet delmwn,able)
33a. Certifier NOM onyone)
Certifying ph 91e19n(Physldan 0Neykgpesed dcadwh98911311191 physician has prmouneeddad e4amdded Ilan 23)
To thebestofmyknowledge, deedoccurredduetoWecouse ts)andmannerasdated.
Pronouncing ndeenUyingphysldan( Phyddao.bodpromndngdead end cerAi g0mesaddead)
Tolhebe st 1 myknowledge ,dathoccurredIt lheUme, date, and plece ,end des toDeceuee(9) and mxuerlert ed_ I:1
Media!Exerdner /Coroner
On Um bails of ex9Mndlon end or lnvadlgdlon, in my opinion, death ocmr,sd sl lhs 015, date, sad pisce, and duo to Ms UUxe(e) and nom es 9bted- DA
339149T034
1 U1'11 A
�AJ
3c llcemeNumber
DatayS' Iliad 9. OI
34 end micas �j rmny�g°C08I d cause a Dad (ham Toe 1PJ
.�'h 0 .FF 4 +Jn
II$ Flue gage Qacie +a9 lcmi.
n•Y
p mfsS. IdN l :r
/I i 131313 10 11 1
36. Dale Flsd(Mod,day,year)
`1- 1 -I
1I Al
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.
HI0S.144 REV 112036
TYPE/ PRP1TIN
PERMANENT
BLACK IM(
L.-
7825368
WARNING: It is illegal to duplicate this copy by photostat or photograph.
No.
COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF HEALTH VITAL RECORDS
CORONER'S CERTIFICATE OF DEATH
(See Instructions and examples on reve se)
OsposkionPerunN% D 7 Up (J(
Marina O'Reilly Matthew
State Registrar
February 11, 2014
STATE FILE NUMBER
Date
065140
Decedent: State File Number:
Name: I Clair E. Miller' :•E:i:'
Gerid Male l: SoCiai•SaCuritY NUmber:
:Date of Birth: April 28, 1937 Age at the Time of Death:
D ate and Place of Death:.:
ate of Death: July 01, 2013, County Of:Death:
City.ofDeath: Afton
L o cation: SterValleMedical Center 110 ,HOspital"Oane
pthar.,Significant v. 1. 1.......,..;;--
:::j•:
.''r.f ...3i...
Manner of De Natural Death il Me: Of 'Death
ertifier
Physician
Michael Pieper, D.O...'
dee0: Hospitattap6,.PO'pox:579,.Afton,'.1tyy:OmIP831
August
This is a true certification of the document on file in the oifice of Vital
StatisticaServices,Chayenne, yVyoming.
DATEAS8UED: Thursday,:july 03; 2014
This topy:is not valid pnleas prepared on paper with.an engnyed border.
ilfanttr :atititcf,,irVv• V"
di 'CERTIFICATION wyregat4r RECORD
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