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MINNESOTA
STATE OF ~A'C(®M~,~
COUNTY
HENNEPIN
RECEIVED
LlbtCOLR COt!i''ITY CLERK
AFFIDAVII OI! ,F I t SHIP
Westport
ececem'uwner No: 53410
::'"i~'~'edent Name/ Donald B. Anderson, Jr.
Lease Number: . :WY5116, 5117, 5118, 5119.01
Lease Name: C.I.G. Federal 1-10, 2-10, 3-10, 4-10
ti
) Legal Description: Township 20 North, Range 20 West
) ss. Section 10: All
· ) r
BOOK ~I~PR?A~E 0 5 ~
BEFORE ME, the undersigned authority, on this day personally appeared Gary R. Br,akke
well known to me to be a credible person, who being by me sworn to tell the truth, the whole truth, and
nothing but the truth, made the following answers, in my presence, and having completed said answers,
he/;¢~ subscribed them in my presence, and swore the same were true to the best of his/ll~
knowledge and belief.
State your name, age, and present address:Gary R. I~'akke, 55, 5424 Shoreline Drive,fCbund ~ 55364
Were you acquainted with Donald B. Anderson, Jr. (the "Decedent") during his/her lifetime? Yes
How long did you know the Decedent? 15 'years
Approximate date of his/l~r death: October 3, 2002
State whether or not the Decedent was ever married. Yes
(a)
(b)
'(c)
(d)
(e)
(0
How many times? 2 1. Kathryn Sc. hilt - 11/80.
Name of spouse or spouses and approximate date of marriage of each: 2. Rebecca 30 Gr~/17/87
State whether spouse(s) are now alive or dead, and if dead, give approximate date of
death: Kathryn Schilt is dead; DOD approx. 11/85: Rebecca ;30 ~ Anderson is alive.
Did any spouse leave any will within your knowledge?
Within your knowledge, was there any administration of any spouse's estate? No.
If so, where,
If Decedent was divorced from any spouse, state name, date, and place of divorce:
N/A
Did the Decedent leave any will within your knowledge? Yes.
Was there any administration of the Decedent's estate within your knowledge?
If so, give name and address of Executor or Administrator
NO.
and where such administration (is) (was) pending:
If you have answered that there was no administration of the Decedent's estate, please state to
the best of your knowledge what debts, if any, were left by the Decedent: None.
9. Give names of all Decedent's children, including adopted children, if any, and including any
children who are now dead, and give the present addresses and ages of all living children:
If Deceased Social Security or
Name Address Age Date of Death Tax ID No.
Patricia Anderson, 3106PriestUane, Mound ~N 55364 19 years old. Wiving SSN 520-19-7239
Aidan Anderson, 3106 Priest Uane, Mound MN 55364 7 years old. Living SSN: 474-29-2594
William Anderson, 31136 Priest l~ane, rq}und M~ 55364 5 years old. L'iving SSN: 471-33-8794
NOTE: If no children are dead, Question #10 need NOT be answered. N/A
10. (a) If any children are dead, state whether or not any such child left a will:
(b) Give the narne and present, address of any surviving Spouse of each such deceased
child: ' '
(c)
Give the names of all children, both living and dead, of each such deceased child and
the present addresses of all living children:
Name and
Child of Address Age
If Deceased I Social Security or J
Date of Death Tax ID No.
NOTE: If Decedent was survived by children or children of deceased children, Question #11 need NOT
be answered. N/A
11. If the Decedent was survived by neither children nor their descendants, please answer the
following questions:
(a) Did the Decedent's father or mother surviVe him/her, and if so, give their names and
present addresses:
Name Address I Social Security No.
(b)
Name
Name all brothers and sisters of the Decedent, both living and dead, stating the ages
and addresses of those now living and the date of death of those now dead:
Address
J if Deceased
Age Date of Death
Social Security No.
(c)
If there are any deceased brothers or sisters give the names, addresses and the social
security numbers of the surviving children of each:
Name [ Address
Age I Child of
ISocial Security No.
Subscribed and sworn to before me, on this
Notary Public in and for He-nnepi n
County, State of Minnesota
11th
__ day of
February
,20 03
STATE OF
COUNTY OF
CORROBORATING AFFIDAVIT
(TO BE EXECUTED BY PARTY OTHER THAN THE ABOVE AFFIANT)
MINNESOTA )
) SS.
HENNEPIN )
Nancy Rehberger
., of lawful age, being first duly sworn, on oath states:
That the affiant was well and personally acquainted with the Decedent in his/hmx lifetime; that this affiant
has read the foregoing Affidavit of Heirship, knows the contents thereof, and that each and every
statement therein contained is true to the best oNxi~/her knowledge and belief. ~FFiA~ .~.~
Subscribed and sworn to before me, on this_ day of February 11- ,20 03
SEAL .....
Notary Public in-an,~for Hennepin
County, State of
NOTARy PUBLIC-MINNESOTA
I~IMY COMMISSION EXPIRES 1'31-2005