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Home My WebLink About907447 AFFIDAVIT OF PROOF OF HEIRSHIP OF TO THE PUBLIC NAME OF DECEDENT of lawful age, being first duly s~,orn, according to law, deposes and says that ~ ~'-.,~t~.,'~n~'-of the su~iving relatives and that the said ~~/Z~C ~'~ ~'~/Z~ed this life at or near ¢~~ in the County of ~/~ Z&~ , in the State of ~~k ,on ~d~ ~V being ~ years of age at the of ~ death. The affiant further swears that the following is a true, correct and complete statement of the family history of said decedent, and shows all persons who can be heirs at law. Was the decedent married or single/ a widow or widower at time of death? //F//~,/4~ff married/a widow or widower, give name of husband or wife ~,~t~'-,~-'~ ,~,~_a.,~:~_/,~ .,~-'/~.~-'~'/~f//,~t.4.. ,address Is such husband or wife now living? 4//~ If dead, ~ve date of death Was decedent ever married to any other than above person? ~ / ' If so, give the following information: (List names in order of marriage) NAME OF SPOUSE OF DECEASED LIVING OR DEAD DATE OF MARRIAGE DATE OF DEATH DATE OF DIVORCE If spouse has remarried, so state If deceased had children, name all of them, showing which are adopted, illegitimate, living or dead. If illegitimate, state whether living in father's family or publicly acknowledged by him. LIVING NAME OF CHILD OF DECEASED AGE ADDRESS OR IF DEAD, GIVE DATE DEAD I i I RECEIVED 4~4~2005 at 10:35 AM RECEIVING # 907447 BOOK: 582 PAGE: 314 JEANNE WAGNER LINCOLN COUNTY CLERK, KEMMERER, WY LD-644 P9 1(7-89) Printed ~n U SA. State below whether or not deceased children, including adopted or illegitimate, left descendants, including adopted or illegitimate.' NAME OF DECEASED NAME OF CHILD OF DECEASED ADDRE IF DEAD SON OR DAUGHTER SON OR DAUGHTER GIVE DATE NAME OF DECEASED SON OR DAUGHTER NAME OF DECEASED / SON OR DAUGHTER// DO NOT COMPLETE the remaining questions if the decedent left a surviving spouse and surviving children (or descendants of deceased children. Did the decedent leave parent or parents? J LIVING IF DEAD NAME OF FATHER AND MOTHER AGE ADDRESS OR DEAD GIVE DATE FATHER MOTHER If deceased had brother or sister, give names, showing whether of full or half2Blood, adopted or illegitimate. BROTHER ///// LIVING NAME OF BROTHERS AND SISTERS OR I AGE ADDRESS OR IF DEAD, GIVE DATE SISTER DEAD / / // State below /f any deceased brother(s) ory~/ter(s) had children. Name each one, whether living or dead, and give the information called for in the blank form. / NAME OF DECEASED HI SED LIVING IF DEAD ~tBt'~TI~:[:I t~[~ ClSTI::~ / ..... HE ..... ._...T_., ADDRESS OR ................... DEAD GIVE DATE / / '.EIRS OF DECEASED BROTHER(S) OR SISTER(S) (CONTINUED) NAME OF DECEASED NAME OF CHILD OF DECEASED BROTHER OR SISTER BROTHER OR SISTER AD .. E S NAME OF DECEASED BROTHER OR SISTER .,/ // ,/ IF DEAD GIVE DATE :tate below /f an)Z/deceased unclctst or aunt(s) had children. Name each one, whether living or dead, and give the information alled for in the~lank form. S/ UNCLE LIVING NAME OF UNCLES AND AUNT OR AGE ADDRESS OR IF DEAD, GIVE DATE AUNT DEAD // NAME OF DECEASED NAME OF CHILD OF DECEASED UNCLE OR AUNT UNCLE OR AUNT AGE NAME OF DECEASED UNCLE OR AUNT NAME OF DECEASED UNCLE OR AUNT .A ~ame each uncle and aunt, whether living or.,dead, and indicate whether PATERNAL or MATERNAL. Give all information ailed for in the following blanks: / ADDRESS L~RG EAD / IF DEAD GIVE DATE 644 P9 3 I1 891 " o?~[~ll~l/i~lfi~tr'$'~'r(s)"or,~e~. ¢ children of deceased brother(s' )O NOT COMPLETE if deceased left surviving parent(~ )' Fl~J)l~lq~ .'~ nd sister(s), or any combination thereof. ',~, NAME OF GRANDFATHER AND GRANDMOTHER kGE '";'~;;'; "2",';}: DR~;~'[ OR IF DEAD ~tll ~"' 'ii~.'~ ;"i'~ '":~'/ DEAD GIVE DATE PATERNAL GRANDFATHER PATERNAL GRANDMOTHER / MATERNAL GRANDFATHER / MATERNAL G~NDMOT~ Did decedent leave a will disposing of any part of his or her estate or homestead? Was there an administration of estate of this decedent? 'T-~n what County-Parish? ~- .t?2/- ~-- Have all debts against the estate been paid? Did decedent leave personal property of sufficient value to pay all debts? If decedent was receiving payment for the accruals to any mineral interest in land claimed and occupied by (him) (her) '"7I Subscribed and sworn to before me this ~"/""d'ay of My commission expires / ["~ NOTAnY , ~ - I /~~ FRANK' R, 6P~KEfl State of ~l~+ I Ii/ *l ,oeo so.,. ~- , I t~[ ~/~l sa. Lak. City, Ulah 84101 ~ . ~ ~-~ ,~ ~/~ I !%% W/~/ My Commission Expires oumy oi - I 2007 ~ ~ NTtTE 0~' i~'s'i~ This instrument was acknowled~u ~c~ul'~ mc ~li ............ ' it:' 031", as a homestead, describe and identi~ad land: State? (Relationship) Address: , 19 ,by Notary Public Notary Public My commission expires: Printed name of notary: SUPPORTING AFFIDAVIT We, the undersigned, of lawful age, being first duly sworn according to law, depose and say that we fully understand t facts and statements made in the attached and foregoing affidavit of f37,~/v'~.e_ ; that we are personally acquainted with the affiant a are witnesses to his signature, and also were acquainted with said ~'~..'"~/~'~_ Deceased, and we know that the above and foregoing shows all the kin, relatives,..~../ //~°r descendants~f said deceased2/06=~. '~6 '~O-oI/L~ 5~/~,4 Th'Il /rY~//)/}/,r/Tjf Affiant Address: //f/~' b///~< ~. flY)orr..~ tJT.-/~, 7¢~//2 / Occupation: ~',~ Affiant: ~%)q "-'"~"-'"J Address: C~q Occupation: Subscribed and sworn to before me this -~-'f' day of My commission expires Address: Countyof ~7~L/f ~a~- ' This instrument was acknowledged before me on NOTAIY PUIII~iC FRANK R, 8PlLKER 1030 ~oufh 300 Well Sell Lake City, U{kh 84101 My Commission Expires December'~, 2007 ~TA'FE OF UTAH ;,;vt,a~ y Fub;h. , 19 ,by My commission expires: Printed name of notary: Notary Public Printed in U.S ,County ;~ 8egistrar ............. 4{ ERTIFICATE OF DEATH ~ DATE OF BIRTH (Mo,, Day ~Yr, ii:"']~ ¢i ~ ~]¢'~st ~hday ~R t Y~R J IF UND~ 24 H&S. I e BIRTHP~CE (C y & ~a · ~ Fom gn Count~J 7 SOC ~ SECUR ~ N~BE~ aa P~CE iHOSPIT~¢~s¢4j~:I:~COTHER ipCATiO~S: : ' ~Sb. N~E OF HOSPT~ NURSNG HOME OROTHERFAC L ~ · ~e)-;'~2 E~Ou~e~e~'~'"~!~:¢~70~,~ assisted living Alta Ridge Assisted Livin _. ,. ,, .. ~ ¢ ~ .'~;;,~' ~:~ :, _ g ac. c[~ TO~ OR LOCAT ON Pe b~ ~;~, ' ~ ~OUN~ OF D~TH 9 SURV V NG SPOUSE Of ~le g e ma Ben name DECEDENT 10 WAS DECEDENT '1 ~; ~&I~STATQ~"/,?'~/'?''-' ~ ' 12a. OECEOE~rS USO~ OCCUPAT ON fa., ~¢~ otw~ ~., ~2b aND OF aumNEss Da NDUSmY' ~V,s~2~o - ~re{~. ¢;~40~ Housewife/Secretar Mane ement ' ~e ': '" t7. FATHER'S N~E ~F~ ~'~ ~ :~$;~;~:~ ?. ' ' "~ : ' ' 18. ~IOEN N~E OF MOTHER (Fi~t, Middle, ~) ~A~ENTS ; Mark Clegg Brb~(';~5~;:~;;¢;~' '-, Ada Clare Cu~ings · ';: m ~E ~E~T O~S~ ~ ~0 ~'~'~6~¢;S ~¢ ~¢O~T ' INFORMANT ' ,'... ;~ ~ ;,T~;;;~X~,¢~¢¢~)~¢~ ~:;, ?.. :' ... : Ba~e B. ~c~21'~fi~(S~'~(~5(~I~19' Rsveroaks Dr&ye, Sandy Ut 84093 : ' 20 MErHODOFDISPOSlTIqN?~;~:;3~¢;~I~I~D~TEOF'DSPOSITON 21b P~CEOFDSPOSlTION{name~mete~ 21c LOCATON*C yorTown SEe ' ~-.-',~¢ ~?*;¢~:~ ' 5,,,-'. ', . , crema~ ~'' ~';,..~,:,;~.~L~;~¢%~,~.h~ep .At,.-Zuu~ ~lys~an ~urmaz Gardens Murray. Ut ~ ~51 :~i?"~;.~.~N~~'Ha>~MO ~ DAY /O YE~2~ Salt La~e City, U~410fi ~ 1' CERTIFYING PH+SIC~:f';'~;fg:~'~:~'~I~"~ daa~~` ~e me d .... dp .... ddu. o h ....... ~ .......... d ' 2 b. S~N~TUaE ~o r~ O~'~T~EtE~':~'j~:' : ~ ' ' 27c. LICENSE NUMBER 27U DATE S GNEO (Mort h Day Yeer)' ' ~{~.~;;~.: ~¢::.N~ THiCk,sE 0F D~TH (Bern 311( ~ lO 5EPT~E~ :~ff<5~q:';:~t~'?~,:';> ~y.~g~ tiNTER TH¢ DIS~S(I~ gS?~R'~OMPLICATIONS THAT CAUSED THE O~TH. DO NOT ENTER THE MODE OF DY NG SUCH AS c~mmc m Baleen Onset an¢' isdaa~), ; ..... ~' ! ~2~.~UET00RAS&CONSEQUENCEOF ' ~qenSally Ij~t ~ndi~gns If ~j~, ~p~ TO,OR ~ &CONSEQUENCE OF)' any, leadfng o Im~diate%;;~~~;~'~h ;~?:.,;,3~ ,:¢ , : ', ' ' ~ ~; ./~' (di~e~se PART Il. O~er SignOri 6~Jt~'~;I,~l~'~ ] ~. IN YOUR'DP NION, TOBACCO USE BY THE DECEDENT: 33a WAS ~ AUTOPSY 33b ~RE AUTOPSy ' ~EATH ",':-: ,- ~ ~;~ ' ~;, ~ ~ ~'~t ~4~ ~ ¢ ~; ¢; ,' ~ ~H OR TO COMPLET ON ' , , ~uECd: '; .,: inv.&~{i~ ~ ..~¢¢ .. ~ W.HCuRYoCCUR~Ofenters~ue~ events which msu~ in iNu~ NATUREOF NdURYshou~enter~i~ laM31) ,. , :, ~ ';' ,'.:,:~ .::'. ~',~7~:,,7~,~Z ~L~;:,~., ', :%:,, ;:.' . ' .' office. This certified copy is issued 953 As Amended. DIRECTOR OF VITAL RECORDS *01491198, ~rom: Sent: To: Subject: Lewis, Artricia (ArtriciaLewis) <ArtriciaLewis@chevrontexaco.com> Wednesday, February 23, 2005 12:58 PM "BAYNE B t4C*M:[LLAN" <baynemcmillan@msn.com> RE: Geraldine B. McMillan--Business Associate 02995101 Bayne -the requested legal descriptions. if you have any questions. Thanks ~ Artricia Pleaes do not hestiate to contact 004636 - LABARGE UNIT-TERTIARY - LINCOLN AND SUBLETTE COUNTIES, WYOMING TOI~qSHIP 27 NORTH -RANGE 113 %TEST, 6th pm, SECTION 22: SW/4 SW/4; S~ction 27: NW/4 NW/4, S/2 NW/4, SW/4 SW/4 SE/4 SECTION 28: E/2 E/2; SECTION 33: NE/4 NE/4; SECTION 34: W/2, W/2 E/2, SUBLETTE COUNTY WYOMINGAND 26 NORTH - 113 WEST, 6TH PM, SECTION 3: LOTS 2,3,4,5,6,7,10, 11, 12, SW/4, ~W/4 SE/4; SECTION 10: W/2 NW/4, NE/4 N~/4 LINCOLN CO~TY, ~£OMING 004650 GOV'T MINTON 'A'- SUBLETTE, I~fOMING TOWNSHIP 27 NORTH RkNGE 113 WEST, SECTION 21: SW4SW4; SECTION 28: NW4NW4 S/2N/2, N/2S/2, SE4SE4, 004714 - GOV'T MINTON 'B' TOWNSHIP 27 NORTH RA/~GE 113 WEST, SECTION 21: NW4NE4, NE4~4 SW4SE4, SE4SW4 SECTION 28: LABARGE BEAR RIVER PA- LINCOLN AND SUBLETTE COUNTIES, W~ZOMING TOWNSHIP 27 NORTH -P3d~GE 113 ~ST, 6th pm, SECTION 22: SW/4 SW/4; Section 27: ~UW/4 NW/4, S/2 NW/4, SW/4 SW/4 SE/4 SECTION 28: E/2 E/2; SECTION 33: NE/4 NE/4; SECTION 34: WI2, W/2 E/2, SUBLETTE COUNTY~TYOMINGkND 26 NORTH - 113 WEST, 6TH PM, SECTION 3: LOTS 2,3,4,5,6,7,10, 11,; 12, SW/4, ~'~W/4 SE/4; SECTION 10: W/2 I~/4, NE/4 N~/4 LINCOLN COUNTY, ~ZOMING LABAF~GE CONSOLIDATED OT&ST FR PA TO~TNSHIP 27 NORTH -RA]'~GE 113 WEST, 6th pm, SECTION 22: SW/4 SW/4; Section 27: ~/~ NW/4, S/2 NW/4, SW/4 SW/4 SE/~ SECTION 28: E/2 E/2; SECTION 33: NE/4 ~/4; SECTION 34: W/2', W/2 E/2, SUBLETTE COUNTY WYOMING A/'~ 26 NORTH - 113 WEST, 6TH PM, SECTION 3: LOTS 2,3,4,5,6,7,10, 1!, 12, SW/4, ~/4 SE/4; SECTION 10: W/2 ?~/4, HE/4 ~/4 LINCOLN COUNTY, 9~fOMING Artricia Lewis Land ,D,~ership and Systems Tel 713-752-3D72 Fax 713-752-3040