HomeMy WebLinkAbout889578heim+:ip.doc
PROOF OF DEATH AND HEIRSHIP
(FILL IN ALL BLANKS)
STATEOF ~Ov-~'t lq.~ 889578
coUNTy OF ~
RECEIVED
LINCOLN COUNTY CLERK
of 1/awful agl, l~eing fir;~duly s,~orn according to law, on-oath/s~ysi- ' ? 3 - -
That the statements hereinafter set forth, including answers to questions propounded, constitUte a trfle,
correct and complete statement of the family history of the person hereinafter named as "decedent" and of the
estate of such decedent.
Name of Decedent ~.. L., (... ¢__... 'v'x A, C_~ 0 t*' d
Date decedent died 0c..4-, ~2_q / ;L60} Where?
Did decedent leave a will? ~/e_., S If so, has same been probated?
Or has other administration proceedings been had on decedent's estate?
If so, when? Where?
Were there any unpaid debts or obligations due by decedent at the time of death?
If so, give the following information:
To Whom Owing Amount ' Nature of Debt Paid-Unpaid now
Was decedent surety on any bond at tb time of his death? PO (5
Were there any suits pending, or any judgments rendered in any court, against decedent' at the time of death?
N0
C If so, state briefly the nature, amount involved and parties to the action:
Was decedent married or Single at time of death?
If married, to whom?
Was decedent ever mariied to any other than above-named person?
If so, give the following information: (List names in order of marriage)
Name of Sp(~use Living or Dead . Divorced Date. of Death ov-Di-aqi~-ee
be_c~ j/lo-cc¼ 13,
eo-,-a j Go c &o Iq g i
If decedent had any children b' ny spouse, or adopted an), children, give the following information:
By Which
Name of Child Age Address Living:Dead Date Death Spouse
de.,/'~niq, Co-e~'c~enn6q 7o1,2 S. O~e~s 5+. k; ~;n~
L', I qon¢ CO Sol&?
If a deceased child left descendants, give the followin information:
Living- Date of
Name of Child Age Address Dead Death
Nam~oo/f deceased
child
hei~Thip,doc
Living- Date of
Name of Child Age Address Dead Death
Name of deceased child
Living- Date of
Name of Child Age Address Dead Death
Name of deceased child
In case decedent left no children or decedents of deceased children, then please furnish the following
info atic
Name of Parents Address Living-Dead Date of Death
/[/~ Pather
Mother
Give of brothers and ;isters of decedent:
Living- Date of
Name Relation Address Dead Death
IVlq
~f children of teceased brother or sister: ·
Living-
Name of Child Child of Age Address Dead
tl/ l
Here briefly state facts and circumstances (such as being a relative of, or attorney or agent for, deceased) which
will show basis an¢ source of information hereinbefor~ given.:
Affiant
b¢ir.-hip.doc
/
SUPPORTff,I'G AFFIDAVIT
STATE OF ~ )/~/7//,A/~'
COUNTY OF ~/~ff
~m, ~ ,q, ~: ~~/J~ tiff ~' , of lawful age, being first duly sworn, on o/~th states:
That this affiant was well and personally acquainted with ,
in /d_.d4ff lifetime (being the person described as "decedent" in the Proof hereinabove set forth); that this
affiant has read the foregoing Proof of Death and Heirship, knows the contents thereof, and that each and every
statement therein contained is true, to the best of affiant's~ knowledge, ~/~/~/~~/a elief.// Affi ant
Subscribed and"s'v'~°~,, t° before me this ~ ~'ff"~day of Y//~/~" 20~_,_~
· ' c', :':; o,9 · '
.... '..:/¢N :'
..'i,,' 6'r A ~ ~",';~,.~
NOTARY PUB L/IC
STATE OF COLORADO STATE FIL:E NUMBER.
CERTIFICATE:OF DEATH}- ::::'i: ':::'- ! ? '::::;
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· 524y48~6869~:~ I 90 .':. :~::::[ '~:/:q ::i...{i~ '::i~::~f I. '::::.:. ?: ~:::::' '?J i::Marck: 24, .:1911 ::] Mountain::View,
OYes ~No., ' Ol~palient OER/Oulpalienl ODOA . ~ ONursingHb~e .O Residence ~Othe,(Spec,~ Hospice
:.:...:Porter Hospice at Johnso~..:Ce~ter it to Arap~hoe
:~': ~ ......... ~ b~d.} . Divomed(Spe~;lM -' '~: George Dewey:~' /': '~:~; ';:
Motel.'~er Wid6wed :': Cordon - ,.:
cdibrado :J~ffe~son~' .-::;.'z::711-3 West ~fi'~daiie;~Dr~e
x"? S0~2a. ;~::.:t~iie~'~..: i::/ :'. ~::;::'::;'~:12~::~:
John Cordon:':+ Son
~{he*N~)~:-'~ ~, ~ ::::' ~-~: ':-" ' : ~: :e' .:::F:' /:::.L .;:::~
'~ans'~o.n:~:C~.:.~.eme Evans ~on, gy~a~ng .... .: ..
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0ct0be~ 29, 2001
31_ NAME OF A~ENDING PHYSICIAN IF OTHE~ THAN.~ERTIFIE~ (Fyp~int) .:.. :~( ~;~:: '.:.: .... .:: c:.: '
O Acc deni
<:': :"0 Sui~ldo ~ Manna ~e. ~LACEOFIN~U~Y-AI ~o~ farm eNeel I~t~ 0ffi~ 13~. L~TION Street and Nu~et d~RumlR~ e N~be~,C~,~u~,~ ·
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34. IMMEDIATE CAUSE IENTER ONLYONE CAUSE ~ER LINE EOR P~t (9/' AND ~c). Do not enle[ mo~le~ o~ dy ~g (e:~ ~lrdl!c or Reap~ralo~ NresOalone. ~ tnte~al between onsel
:~ CONDITONS" 3UE. TOORASACONSEQUENGEOF- -" ~ andd~aih '
~::. UNDERLYING CAUS~
THIS IS TO.:CERYIFY THAT THIS IS :A:TRU~.~ND CO~RE~T ~:~OPY_ DE THE:O'¢FlClAL RECORD WHICH iS IN?MY CUSTODY::
:'~..::. scm and signature of the ~Re~stra.~ P~A~ BY'~W, ::Section::::::25-2-l~t8, Color'do Re~sed
Statutes, 1982, if any person alters, uses, attempts to use or furnishes to another for deceptive use
-~:. ':- anY vital statistics record. NOT~:.~ALIDIF PHOTOCOPIED. ~-: :' : .....