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Aff - Williams, Mary R._4/14/2005PROVIS � 'COUnTY HEALTH DEPARTMEN'P�. OF DEATH - BURIAL 7'R�SIT PERMIT '� f: �._:-.: . ' s' �/ _ _.�� A- REPORT OF DEATH (To be compined by faciliq� w�here death occulred) �� -, � � N.\.\IE OF ' DATE OF �� DECE.ISED �Q \fiddl< � ��" - _ DEATH O O TIJ1E bi ( ; . 1� :__ - _ �� COU'TY CITI' � _ OFDEATH G1 �SOYI OFDEATH_�i,�p_yic�,_�1p� AGE�SE � - PWCEOFDE.\TH �2'�_�_C�.O_Ti.-�j_'1,"Z. _ (Give stree� address rt not faality such az hospital, rmrsing home, eic. ) \ameof � � 1 �(edical Cmifitt K,_�U.,rr � .\ddress �j��y �,g{p_�y_ 1�l Phone_ (OBicial cMiLa of cauu o(daath) r� — B- RELEASE (To be completed b�� person Fw�ing amhori[y �o release rrniains) IS fIEREB7' GR.4VTED TO RELE.IiE THE RE\(AIVS OF THE Home) \.1.\IED TO: � C- BIJRIAL - TRANSIT PEFL�SIT (To b< compleud b�� (unaral dvenor or rryresentative) I, REPRESE\TI�G HEREBI' ACCEPT THE THE21\fE LI\!IT ESTA of funeral home) (Cin) � �� 9,0� � f � A 5-p �p0 � s 9G O�T O,fl THE ABOVG \A.\(ED.4\D AGREE TO SECURE AND FILE A CO\fPLETE CERTIFICATE OF DEATH N'I ;HI� (Printtd \ame Funeral D'veaor Licenx �o.) A CF.RTffICATE OF DEATH HA\'I\G BEE� FILED OR A PRO\'ISIOVpL \OTIFlCATION OF DEATH RECEIVED AS REQIRRED B5' L4K', PER\fISSIOV IS HERE87' GIVE\ FOR TR.lVSPORTATlO\ h\D DISPOSITIOX OF THE RE�f.VNS - ECCEPT FOR CRE\tATIOy WHICH REQUIRES A COVPLF,TEDCERTIFIG\TEOFDF,ATH. - j /�//�%/ - �� � �� � ���// LLiO�Ip . � � - l` / %'% " ! •' V (/ LOC.LL. �U\18ER FILE DATE (HE.U.TH OFFICER SIG�A'I�� D- RESIDENCE (To be campl.td b�� Funrral direnor) LAST }:�O11'\ L1ST f:\ON'� ADC COCITYOFRESIDE\CE_ •I SO/'7 DECEASED�j'/3 (SVeet) 1? ADDRESS 2}'R5. PRIOR TO DEATH Q(diBerenQ (svaeq (Cfty) (Stata) (Z�p) (Street) (Sute) E - DISPOSITIO\ ('!o be zigied \,L\fEOF i PLACE OF DISPOSITION seuton of cemetery' or representa[ive ofcremamrc) ✓ Q /� t tJy' �[ETHOD OF DISPOSITIO\ (Check all that apply) Burial _ Crttnation f Entom6mrnt _ Inummzm _ Donation _ Remoced (mm S�atz _ DATE OF DISPOSITIOV � DATE OF CRE\fAT10\ CRE�fAI\SRETIiR�F.UTOFL'�ERALDIRECI'OR � !/ FA:VILY �., SIG\AItiRE OF SF'_YTO\ OR CRF,\fATORI' HEPRESEXT (SUte) Scattering _ l.ocalion o(Scarimng 7 - ;'�-C� `F CEJfETER\" I. t�T t: CaCY-HSI�h deG�rn� + capY. To �eeomG�Y Ne boCY w ib EuWU�mi .�tus� oe s4���e�Y �n: sex�yy vie cnnc��y w u�c �m�ocnu�._ �� ��_..�. �.,�>.... � .....................r- ....--. �- coun�� wh�e �he En�h oawrM.iihvi t dals aftR bw�l m crem.00n. Copn m+Y �^u� f°1 �LO^d. Con�ct bed h aRh depuvnnu !m outol-wte sh.:pmnu. t. YeOow Cvpy"-Cem:tery'�Crmu:ory �opy for Nev fcemd�. 7. W�4 Copy--To be meJed by Ihe faeiLly n'hne �he EnN aeurteC b ihe IocJ heJN depetvnent nUijn ]J Ip�1s (oDOxvig dath Copin af ehe �F �_ fortn r.u5 � m�de by ��e Levh�' (oe iu' recm'u �M (m 4ev^g vm liv a(mailr.g. SDH 06-093-32 SF' 38220 (R/1-96) _. � STATE OF INDI.��1A COiJNTY OF GIBSON ) )SS: ) � 00 5- O 6� 6g -� r1FFIDAVIT FOR TRr1t�ISFER OF REAL PROPERTY Eric L. Williams, James E. Ross and Helen N. Compton being first duly swom upon their oath, depose and say: That Mary R. Williams died intestate on July 7, 2004, while domiciled in Gibson County, Indiana. 2. 3. That forty-five (45) days have elapsed since the death of the Decedent. That no application or petition for the appointment of a personal representati�=e is pendin� or has been �anted in any jurisdiction nor is any administration contemplated. 4. That Eric L. Williams, James E. Ross and Helen N. Compton are claimants of said Decedent and are entitled to receive payment or delivery of property of the decedent, without administration, for the followine reasons: The decedent died intestate and Eric L. Williams. James E. Ross and Helen N. Compton are Decedent's le�al heirs. 5. That the value of the Decedent's �oss probate estate, less liens and encumbrances, does not exceed the sum ofTwenty-five Thousand (525,000.00) Dollazs, as provided by I.C. 29-1-4- l, the costs and expenses of administration and reasonable funeral expenses. :,� APR 1 4 2005 `� � ��. GIBSON COUNTY AUDITOR � � 6. Ihat amon� the Decedent's assets is a parcel of real estate which was owned by the Decedent commonly Irnown as R. R. 3; Box 322, O�vensville, Indiana; 47665, situated in the County of Gibson, State of Indiana, more particulazly described as follows, to-wit: Part of the Southwest Quarter of the Southwest Quarter of Section Sixteen (16); Township Three (3) South, Range Twelve (12) West, in Gibson County, Indiana, and more particularly described as follows: Beeinnin� at an iron on the West line rivo hundred riventy-four (224) feet North of the Southwest comer of said quarter quarter section; thence North alone said West line two hundred forty-eight and ninety-one hundredths (?4891) feet to an uon; thence East and paraliel to the South line of said quarter quarter section one hundred seventy-five (175) feet to an iron; thence South and paraliel to the West line of said quarter quarter section lu�o hundred forty-eight and ninety-one hundredths (248.91) feet to an iron; thence West and parallel to the South line of said quarter quarter section one hundred seventy-five (175) feet ro an iron at the point of beginnine; containing 1.00 acre, more or less. Subject to easements, rights-of-way, high�vays, roadways and buildine and use restrictions of record and existing public hi�hways and roadways. Subject to any and all prior reservations and/or conveyances of coal, oil, gas and/or other minerals in and underlying the above-described real estate, provided that Grantors do hereby convey to Grantee all of the Grantors interest in coal, oil, gas and other minerals. 7. That there are no creditors of the decedent so far as known to Affiants. 8. That the individuals entitled to the real estate as a result of the Decedent's death are the following, namely: Eric L. Williams Son 11131 �Vest U: S. 6 �Vesri ille, Indiana 46391 James E. Ross Son Route 3. Box 322D Owens�ille, Indiana 4766� Helen \T. Compton Dauehter Route 3, Box 321C Owensville.Indiana 4766� m � � 9. That no inheritance ta�c is due by reason of�ecedenYs death, because no transferee receices ta�cable transfers in excess of such transferee's exemption from inheritance tax. �= � �✓.�GG� Eric L. Williams .-,��,,.���"�— � ,�ames E. Ross ��.� !� �.�,�.,�,�•�.-- Helen I�T. Compton STATE OF INDIAi\TA ) ) SS: COLT\TTY OF C� 1. � S� � ) Before me, the undersi�ed Notary Public, in and for said County and State, personally appeazed the �vithin named Eric L. Williams �vho acknowled�ed the execution of the foregoine, instrument to be his voluntary act and deed. WITI`TESS my hand and Notarial Seal this `f day of � p � I� , 20d�. — �l C�7�.i � � �/!���r�! Si�n tureofl�TOtary blic VV c2l7� S- ��15 /�!r� Printed 1�'ame of I`TOt ublic My Com.-nission Expires: � �i-� �i-'—O� Residence of Notarv Public: G1 b S o� County, Indiana sTATE oF r�ra�vA � � ss: COLTiVTY OF � 1 /� Su ✓ ) Before me, the undersigned Notary Public, in and for said County and State, personally appeared the within named 7ames E. Ross �vho acknowledged the execution of the foregoing inshument to be his voluntary act and deed. :. � � �VITNESS my hand and Notarial Seal this ��day of �o/� i 20 � �—' My Commission Expires: Nai�. :�� �4� �— Residence of 1\TOtary Public: l� t%� t� County, Indiana STATE OF I\TDIr1i�1A ) ) SS: cou`� oF G ��� s� � > .g,. � a-_ .r�J Paa,� Signature of Notary Public SLcsa ✓ �. Pr�Kc Printed Name of Notary Public �.`�, SUSF.N G. FARlCS �. �,• �::f'-�. ,:a�rv F�_::.. s,_,3 0� i-c c.� Ny Commissbn F�W^I%s Ncv. -ti. :E=5 Before me, the undersi�ed Notary Public, in and for said County and State, personally appeazed the within named Helen N. Compton who acknowledeed the execution of the foresoin� instrument to be her voluntary act and deed. V V WITNESS my hand and Notarial Seal this My Commission Expires: /I -��-�,7 Residence of Notary Public: G 1 r�� r1 County, Indiana � day of �%P r' I I , ��.� ���-�. � Sign)ature of Nota�Public �ti�� r d-e, S_ � rl F J�� Printed I�'ame of Notary-�ublic This Instrument prepared by Tunothy J. Hambidge, Attomey at Law. , C STATE OF I�IDIANA COiTiVTY OF GIBSON ) )SS: ) •D o 5 -o� � �� - � AFFIDAVIT FOR TRANSFER OF PERSONAL PROPERT]' Eric L. �Villiams, James E. Ross and Helen N. Compton being first duly s«om upon their oath, depose and say: That Mary R. Williams died intestate on July 7, 2004, and at the time of her death was domiciled in Gibson County, Indiana. ?. 3. That fur[y-five (�}�) days have elapsed since the death of the decedent. That no application or petition for the appointment of a personal representative is pendin� or has been granted in any jurisdiction nor is any administration contemplated. 4. That Eric L. Williams, James E. Ross and Helen N. Compton are claimants of said Decedent and are entitled to receive pa}�nent or delivery of property of the decedent, without administration; for the following reasons: The decedent died intestate and Eric L. �Villiams, James E. Ross and Helen N. Compton are Decedent's legal heirs. 6. That the value of the decedent's eross probate estate, less liens and encumbrances, does not exceed the sum ofTwenty-fi��e Thousand (525,000.00) Dollars, as provided by I.C. 29-1-4- 1, the costs and expenses of administration and reasonable funeral expenses. i. That the follo���in� is a full description of all the personal property belonging to the decedent according to the best kno�vledge and information of the Affiant herein: fi. Q 1965 ELC mobile home Fifth Third Bank Checkine Account rli37744 Household goods and furnishings That there are no creditors of the decedent so far as kno�vn to Affiants. That the individuals entitled to the abo��e described personal property as a result of the decedent's death are the follo�ving. namely ,4 APR 1 4 2005 �� �� GIBSON COUNTY AUDITOR � Eric L. Williams 11132 �Vest U. S. 6 �Vesn�iile, Indiana 46391 James E. Ross Route 3, Bos 322D O�vensville, Indiana 4766� Son Son Helen N. Compton Daughter Route 3, Box 321C O�vensville, Indiana 476�5 � 10. That no inheritance tax is due by reason of decedent's death, because no transferee recei��es ta::able transfers in excess of such transferee's exemption from inneritance tax. STATE OF INDI?.i\'A COWi TY OF GI 6So� ) ) SS: ) � �� . f�L`�"— Eric L. Williams o�sT.i✓G `.%hZ— es E. Ross `-t�-,ti 1J C�.�,-.. c,��.,� Helen N. Compton Before me, the undersigned Notary Public, in and for said Coimty and State, personally appeared the ���ithin named Eric L. Williams, who ackno���ledged the execution of the foregoin� instrument to be his voluntary act and deed. S �1%ITNESS mv hand and Notarial Seal this � day of � , 200�. ���_ �,����t Signature of No ary Public �ti�2 n �� S_ C�� �, ��� � Printed Name of Notary Public b4y Commission Expires: � I- ZG-v'] Residence of\'otary Public: � i {�5.:'� County, Indiana � � STATE OF INDIANA ) ) SS: COiJ\rI'Y OF G� 1�sv l� ) Before me, the undersigned Notary Public, in and for said County and State, personally appeared the within named James E. Ross who acknowled�ed the execution of the foregoing instrument to be his voluntary act and deed. 5' �VITNESS my hand and Notarial Seal this ��day of r' ,200� � � 1 �RiU'-2 Signature of Notary Public My Commission Expires: �✓{��� a � ad� c� Residence of iotary Public: G /65�� Count}', Indiana STATE OF I�TDIAI`TA ) I ) SS: COil�'TY OF � I D S��"' ) S i,�5 a,v �. f a r� t Printed I�Tame of Notary Public ���� SUSF.N G. FAR{F ` SEP-�L , Nacry FuS:ic. Sf=1a of I�d!c.� My Commisslon Ezpires No�. 2q. Z�'=6 Before me, the undersigned Notary Public, in and for said County and State, personally appeared the within named Helen N. Compton who acl:nowled�ed the execution of the fore�oing instrument to be her voluntary act and deed. �VITNESS my hand and Notarial Seal this � day of �(� � I I _, 200� /' %��l�.G�t✓ f /-f c�N-c L'%/t,�l Signature of Notary Publi� ���Q.7 �� c� .S c, �ef ?rnted Nanie of No ry Public Nly Commission Expires: ll�.�cJ—G �% Residence of Notary Public: G/ bso� County, Indiana This Instrument prepared by Timothy J. Hambidge, Attorney at Law.