HomeMy WebLinkAbout906570AFFIDAVIT STABLISHING SUCCESSOR TRUSTEE OF THE
CATHRYN CARMEN BERTA FAMILY PROTECTION TRUST
STATE OF ,./_x/,~.~_.,, )
· SS.
OF )
RECEIVED 2/18/2005 at 10:53 AM
RECEIVING # 906570
BOOK: 579 PAGE: 236
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
I, ORESTE JOSEPH BERTA, being first duly sworn, on oath depose and state that I am
making this Affidavit to establish the death of CATHRYN CARMEN BERTA and the
appointment o£the sole successor trustee of the CATHR'~ ~'N C~MPdVIEN BERTA F.~,{ILY
PROTECTION TRUST, as hereinafter set forth, and that I make the following statements in
connection therewith:
1. I am the named Co-Trustee of the CATHRYN CARMEN BERTA FAMILY
PROTECTION TRUST, dated December 1, 1990, and have personal knowledge of the facts set
forth in this affidavit.
2. Said CATHRYN CARMEN BERTA FAMILY PROTECTION TRUST provides that
Co-Trustee ORESTE JOSEPH BERTA is appointed and nominated as sole successor Trustee on
the death of CATHRYN CARMEN BERTA.
3. CATHRYN CARMEN BERTA died on October 12, 2004, the facts of said death
more fully appearing on the duly certified Certificate of Death, attached hereto and by this
reference incorporated herein.
4. This Affidavit is being filed of record to make of record the death of CATHRYN
CARMEN BERTA and the appointment of ORESTE JOSEPH BERTA as sole Successor
Trustee of the CATHRYN CARMEN BERTA FAMILY PROTECTION TRUST, which trust is
dated December 1, 1990.
DATED this o2~ day of ~~~.~z~~ 2005.
ORESTF~OS'~ 5L~RTA
The forego_in~ instruments SUBSCRIBED, SWORN TO AND ACKNOWLEDGED
before me this J4 ¢ day of (.--~/z,~zz~ 2005, by ORESTE JOSEPH BERTA.
WITNESS my hand and ~l~cial seal. ff
My Commission expires: O~/~ 7/~ 7
Notary Public
~ Notary Publio [
~ 8rate of Utah g
My, Com~ll~logt F, JtSdll~ May 27, 2~7 [
592 N M~ ~1 ~l~Oeorfle, UT 84790&
STATE OF UTAH - DEPARTMENT OF HEALTH
CERTIFICATE OF DEATH ST^TEF,[EN..EER ~ '~ 0,~.O 7
i t. NAME OF DECEDENT FIRST ' MIDDLE : '' . LAST 2. SEX 3a. OATE OF DEATH (MO., Day, Yr) ~b.T~MEOFDEATH(24~¢~c~
~ C~ · C~en ' Berta ~F~la ~ Oct 12, 2004 ~ 1700
Dec 24 1924 ~ 7g I I ~ [ Casper~ Wyomin~ ~ 520-20-67~0
~ ~ (HOSP~T~: (~au~~y} ~L OTHER LOCATIONS: Bb. NAME OF HOSPITAL, NURSING HOME OR OTHER FA~LI~D
~. ...) t~='E~°"~"~"~ U'"."o~ U7.°~'~('"'~)- ~zx~ ~=zo~
:.; ,~'. ~rg. ' ..... ' Iw. nhington [ O=..t. Jos.ph
, ~IYes~ZN. ~2. Ma~ed ' ~4. Divo~d ~o~k.= o~ Home
. 13e. INSIDECI~ 13t~PCO~E 14. WAS pECEDENT OF ~SPANIC ORIGIN? ~l. Yes ~2. No 5 ~CE-Black, Whit~,~, 16.~DUCATON(a~my~,
, ~ ~iMITS? . , (1~ ye~ Spe~) ,' Indtan (~ba may ~ ~nte~d). ~e ~) E eme~ or
~ ;, . ~ .]~ · ~ · .,:' · Japanese, arc. (~ped~) Sa~QdaW(~12) Coflege 13-16
~ l,Y~s ? ~ 1. Me~n ~ 2. Cu~n m17+}
L~e ~lver · ': ~ ' Ca~erine Ferrel ,
~. DATE~S~ /~ ~2~.llnotc~6~bym~i~lex~tn~r.w~d,a~rep~M.E.? n 1 Yes
· .' ~ M.E. ~SE NO. ~ HR~O DAY Y~R
27e: CERTIFIER ' : .' . '..;
ZS. ~E ~D ~DRESS OF PE~ON WHO 'C~qFI~ THE CAUSE ~F D~TH (ITE~
;" ~J':'~:: ~O~F~ ~, ~ ~.D~ 5Z5 ~u~ 300 ~as~ ~Z05, S~. ~o~g,, ~ a4??0 '
"%:; :" ~.REGIST~'SSGNATURE .~ L:~ ~ 30a DATEREGST~RNOTFEDOFD~TH 3~ DATEFLED(~
4~:(~-~?..'~'.;; DUETO(OR~ACONSEO~C~F): ~ {~'' ~ - [/ '' ~ ] J '
-~ :;~:~ ~' ? any I~adlng~'l~edla~ c ' :;' ' :'
· ':' ~:-[ nflaedeven~reiulflngtn ,; '
':':::~: ~'? ' ' P~T ~rSi~m~ntC~d~s~n~uenDbdea~ :' 32 NYOUROPNON TOBACCO USE BY THE DECED~NT '
;:' ;;~'~. ~'~':' ' ~ 3.~d~t~me~useofde.~. ~6 UN~OWN ~1 Yes ~2 No ~ 1 Yes ~ 2 No
' ~:r~ ~ ~' ~'~e ' ~4. H~e '- ' ' ',. d~er passangerorpaoei~n
ReV. I~9~~ j;? ;.~Y. . . :
copy of the certificate on file in this office. This certified copy is ~ssued
the Utah Code Annotated, 1953 As Amended.
Barry E. Nangle
DIRECTOR OF VITAL RECORDS
* 0 i i 3 4 8 8 9 *
5~!0 STATE OF UTAH- DEPARTMENT OF HEALTH-OFF~CE OF VITAL
AFFIDAVIT TO AMEND A RECORDRECORDS AND STATISTICS
THIS AFFIDAVIT FORM ~N ONLY ~E ~S~ TO ~E CORRECT ONS ~ - , ~ AL, ' TH RECORDS 1~ ~O ~
INSTRUCTIONS
DO ~ ~ ~ ~E FIRST SECTION. tem~ la I~r~gn aa. ~e be~ c~plated by ~r oF~ ac~rd ng ~ ~a inf~ti~ ~ ~e ~j~nal re~rO,
~m~, C~e~~ a~d n~s~lng In[o~a~ ~rD NOT m be ~ed in ~ese spas.
~EAD ~E A~IDAVIT, ~ IS BINDING UNDER PENAL~ OF PERJURY. Two ~ent pamons who have ~a~a ~owladge of the a~cy
~S~. s~h as ~ f~ral direct, f~i~ m~.'elc. How~er, one of ~ ~n~ea mu~ ~ t~ iq~. 'The ~alion~lp of ~e ~tn~ m
~ NOT ~ IN SPACE~21 OR ~ ~ ~ m~ed ~r ~o St~e R~rw} " ' "
WHEN PROPE~LY.Cq~L~ED AND SlGNF~ alum ~a ~ m t~ O~ce of~ R~d~ and S[~ttsd~. 2a8 No~h 1460 WesL P 0 8~x 141012. 5LC,
'~oe"~*s L Cath~n I Carmen i Be~a
~.o..~ o.~-s~~,~o.,=m~ LFemale ~Octoberb' DATE O~ EVE~12, 2004 Ij4'P~C;OFOCCURRENGE' Clly aha c~nWSt. G~rga / Washington ~
GgR~F~ATE IS. ~E OF FATHER '
Catherine Fe~el
M~ NO COR~ONS ABO~ THIS LI~
Be. ~T~ ~Y ~ STATE~ ON ~HE ORIG~AL RE~RD J ~. FA~ ~ TH~ SHOULD ~V~ BEEN ~A~O ON THE
~a~ a~ 520-20-67~ ~ 520-20-6753
WHY IS CHANGE
UDOH..OVRS
L: RE~'.
Washi~
h~by cedJl'y, uzx:le~r aenally o[ perjuq', Ina! I have pa~ k~ge of [ha
~nf~ ~ven ts ~ a~
I~. DATE ~IGN~
TO ~E P~ON WHOSE
15. ADDRESS OF W/TNE.~S (gilead. Cii~
288 W. Bt. Georg~ Blvd.
St UT 84770
288 W. St. George B!vd.
DATE SIGNED
H{ATHER L. DU~ON'
State Ol Utah
this is a true copy of the certificate on file in this office. Th s cert f ed copy is issued
2-22 of the Utah 'C~de Annotated, 195'3 As Amended.
Barry E. Nangle
DIRECTOR OF VITAL RECORDS
* 0 I i 3 4 8 9 6 *