HomeMy WebLinkAbout887779 RECEIVED
LINO0I__~! COL!NTY CLERK
AFFIDAVIT FOR COL D DISTRIBUTION OF .; ¢;a'l :,. _.
DECEDENT'S PERSONAL PROPERTY PURSUANT TO W~S!~~r.~,". :~ ~"~::20~,~:,',,:; ~'~ E- R' ~''
STATE OF IDAHO
COUNTY OF MADISON
SS.
BOOK_~.~,~ PR PAGE_~'~/~'
I, Perry L. Robinson, 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'
That Leda Annie Robinson ~- .....
~,e,.,~,,,~ deceased on June 2-, 2002, in Salt Lake
County, State of Utah; that said decedent died testate; that I am the son of the
decedent; 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.
That the value of the entire estate of said decedent, wherever located, does not
exceed $150,000.00.
That more than thirty (30) days have elapsed since the date of death of the
decedent.
That no application for the appointment of a personal representative of said
decedent is pending or has been granted in any jurisdiction.
That decedent's spouse, Horace LeRoy Robinson became deceased on March
2, 1995, therefore, the following named distributee is the sole
,=,~u 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
Perry L. Robinson
Son
That among the assets owned by said decedent was the following:
Beneficial Life Insurance Company, life insurance Policy Number
BL0967148.
The proceeds from this policy are due and payable to the undersigned.
That attached hereto and incorporated herein by this reference is a certified copy
of the death certificate for the decedent.
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 this 29th day of January, 2003.
..... / /P~z/ry L. Robinson
Subscribed and sworn to before
Witness my hand and official seal.
me by Perry L. Robinson, this
day of
My commission expires:
STATE OF UTAH- DEPARTMENT OF HEALTH '
i., ~OCALF,LENUMBER 18-2851 CERTIFICATE OF DEATH STATEF,LE.OM.E. 'i ' ~
· · '-:i:: Leda Annie . ROBINSON Female June 22, 2002 I 1535
:~:' : ' i . ,~. 0~TE OF BIRTH (Mo., Dey, Yr.) 5. AGE- Last Birthday tF UNOER 1 Y~ IF U~ER ~4 HRS. 6. BIRTHP~CE (City ~ State ~r Fore~n Count~) 7. SOCIAL SECURI~ NUMBER
''::"':':~ :~ay 21, 1919 [ 83 [ ..... i ua, ...... I ....... Freedom, Wyoming ~ 520 28 5447
~ckonlv [ ~l.lnp~ti~.l ~ ~ 5. Nursing Home ~ 6. Res~e.~ a.y .
." o~ej;~..,: ~. E~Outpatent. ~3. DOA [ ~ 7.0 h.r (~)', Kospice_ Car~ CareSource - The Residence
,salt:Lake City ' ~:] salt Lake I '.
: ,?i~'~2~ .[.~j:;;; ~ER'IN THE U.S. ' : ' :r'. ..1 du¢ng mo~ of ~'~ ~ ~ NOT entertetimd)
' . ~ ~:j:.~ : '~MED,ORCES? ' ~ ,.NeverMarried ~ 3.~dowed ..~ :Homemaker ~ Home
~.~e~ ~ 2~No ~2. Married' ~ 4, DNo~d
;.. . · ~ 1~. CI~, TO~ OR COMMUNI~ ~ 13c. COUNW 13d. STATE
; ~ l'.Y~s ; .' ~ 1. Mexi~n. ~; 2. Cuban ~ap ...... lc. (Sp~) ~Se~nda~ (0-!2) College (13-161 7*
~-~ 83120 ~ ~.~m~ ~ ~.Om~r¢~) ~tte - 12
'. ~!.: :. '~ ~ilf0id' Lorenzo Jenklns ~nle Mable ErAckson ·
N~Od~NT '
: /.:':Shei~a'.~ddt~s, Dau~hte~,.~,0; ~ox 40~, A~to~, WToming 83~0 " ' '. '
3¢ ~ :.:' 20" "~"¢D °F°ISp°SI~ION '' ' ' ': .'~' 21b P~CE OF DISPOSITION ..... , ~,e~, ,, c. LOCATION - C,,, or Town. S
DISP~SI~O~ '~ ¢.~uda, '." ~ 5. C ..... ~ 6. R ..... ,' 'June '25 ~ 2002 Freedom Cemetery Freedom, Wyoming
Goff Mortuary, Inc.
' ( ~- u.[~c~s~ ~m ~Sdvald, ~tah 8~0~7
: : ' ~ 1. ~RTI~ING PHYSICIAN. To the besl of my knowledge, death o~rred at ~ time. date, and place. ~d due [o Ihe ~use(s) and manner as stat*d
~E~'ER~ ~ 2 ~- RCEMENT OFFICIAL; On Ihe basis o[ ex~l~ anent ~vest~atbn, in my ~in~n, dealh ...... dui Ihe time, date, p,ace and du
. ~ 28..N~ ~O CER~I~ED ~HE C~USE OF D~TH (Item JU fTY~finl) ' '.
;.¢:~/;: ""::~e~' Mtlldr, M.D;', 1624';'EaSt' 4500'South, Salt Lake City, Utah 84117 :
a~a~ST~ '.~ . , ·" '., .~ ' ~ ~. o,~ w.~ ~ 2 :2 2'
~~~~¢ ' ':. : '.. I ~ Ou,e 4,, 00
3~/BA~ENYE~ TME D~S~SE~JURI~. OR COMpLICATIOnS THAY CAUSED THE O~TH. DO NOT ENTER THE MODE OF DYING. SUCH AS CARDIAC '
. .
'.'¢'i; ' :. disease or dohdition ~sultin¢ ~' O (oR AS A CONS~UENCE OF): ~ ~ / ¢ ~ - /
· . ../~ ?,:; Se~ueotialy lisicondi~ons, i[ b.'
2 . '/ an~, leading to immediate : ,~.: :.. ; .:
: ; :~. ~use En er UNDERLYING c. · '
; :: ,;~ '-. ' CAUSE dise'~se or in u~ that DUE TO (OR AS A CONSEQUENCE OF):
;. :':-' ~: ini~ated events resul~ng m
~{?"::: ; dea~) ~ST d.
~X~SE ~F bul n°t re~ul~ng in the underlylng ~use g~en in P~ [ ~ 1. P~a~ly ~tnbut~ [o Ihe ~use of death, ~ 5, NON USER PERFORMED?
,ruer m COM,~ET~O~
':: ~D~YH :':' ~'2. ~a~ ihe ~nder~ ~use ~ dealh...O[ CAUSE OE O~TH7
~ ,'~:~.:~'::.~: ~}~NNERO~D~TH . 35a. DATEOFINJURY(Mo. Da~ Yr.) 35b. TIMEOFlNJURY 3~.INJURYAT~RK? 35dP~CEOFINJURY-Athomo farm street fe~o~,
'~.¢~ ":':'~:. ;' ~. Sq[cid, '::; :' ~ 4. Homicide 35.: LOCATION (Sleet .............. . . .. b ............ . . y .~ ...... ) 35 passengerhorCpedestrian.' a~d..l ,pec~
is.:~o'certii~:t~i 'i~iS(i~ i~ true copy of the certificate On file in this office. This certified copy is issued
in 5-2-22 of the Utah Code AnnOtated, 1953 As Amended.
Barry E. Nangle
:DIRECTOR OF VITAL RECORDS
* 0 1-0 i 4 9 9 4 *