STATE OF COLORADO

COUNTY OF _e,_pa_so _

COLLECTION OF PERSONAL PROPERTY

BY AFFIDAVIT PURSUANT TO §15-12-1201, C.R.S.

NOTICE

If a person or entity holding property of a decedent refuses to honor this Affidavit without reasonable cause, such
person or entity shall be liable for all costs, including reasonable attorney fees and costs, incurred by or on behalf
of the persons entitled so such property (§15-12-1202(3). C.R.S.)

The person or entity paying. delivering, transferring, or rssumq personal property pursuant to this affidavit is
discharged and released to the same extent as if he/she/it dealt with a personal representative of the Decedent.
(§15-12-1202(1), C.R.S.).

1. I, the Affiant, am either a successor of the decedent or a person acting on behalf of one or more of the
successors of the decedent. and I am 18 years of age or older.
2. At least ten days have elapsed since the death of Vlli11,am E. Schwartz (Decedent).
3. The total fair market value of all property owned by the Decedent and subject to disposition by Will or
intestate succession at the time of the Decedent's death, wherever that property is located, less liens and
encumbrances, does not exceed, for year of death (Y.0.0.): Y.0.0. 2015 and 2014, $64,000; Y.0.0. 2013,
$63,000.00; Y.0.0. 2012, $61,000: and Y.0.0. 2011 and 2010, $60,000.

4. This affidavit is not valid for the transfer of real estate To transfer personal property that affects real estate
see§ 15-12-1201(3.5) C.R.S.
5. No Application or Petition for the appointment of a personal representative is pending or has been granted in
any jurisdiction.
6. The Successor(s), listed below, is/are entitled to any personal property belonging to the Decedent, including
but not limited to funds on deposit at or any contents of a safe deposit box at any financial institution, tangible
personal property, and instruments evidencing a debt, obligation, stock, chose in action (right to bring a legal
action), or stock brand. The amount, proportion or percentage that each Successor is entitled to is as follows
(see Instructions):

Name of Successor Description of Amount,

Property Proportion or
Percentage
Rose Arveson Simmons Shnne Inc. AllA»ets All Assets

JDF 999 R6/15 COLLECTION OF PERSONALPROPERTY BY AFFIDAVIT PURUSANT TO §15-12-1201, C.R.S.

© 2013, 2014, 2015 Colorado Judicial Department for use in the Courts of Colorado
 7. The property shall be paid or delivered as described in the following table and then the property shall be
distributed to successors in accordance with paragraph 6 above (see Instructions):

Name of Successor or Person collecting on Description of Amount,

behalf of one or more Successors Property Proportion or
Percentaae
Carson Crisel (Registered Agenl of Rose Arveson Simmons Shrine Inc.) All Assets All Assets

8. Any person collecting property on behalf of one or more successors shall be deemed an agent of such
successor with all the duties of an agent under Colorado law.

9. I understand that any person who receives property pursuant to this affidavit is answerable and accountable
to any subsequently appointed personal representative of the estate or any other person having a superior
right to the estate.

Subscribed and affirmed, or sworn to before me if} the

County of El /4J.io . State of Co/vlttPJ
____• __ , this PJ" day of -il""'ua,L""'"'"'----
20 ../.(;._. by the Affiant. f

---- __,' IJ!lt/20/7

JDF 999 R6/15 COLLECTION OF PERSONAL PROPERTY BY AFFIDAVIT PURUSANT TO §15-12-1201. C.R.S.
© 2013. 2014, 2015 Colorado Judicial Departmentfor use in the Courts of Colorado
 STATE OF COLORADO
CERTIFICATE OF DEATH STATE FILE NUMBER
1. DECEDENT'S NAME (F"irst. Middle, Last) 2. SEX 3. DATE OF DEATH (Monltl, Day, Ye
William E. SCHWARTZ Male January 31, 2014
4. SOClAl SECURllY NUMBER Sa. AGE • 7. BIRTHPI.ACE (City and Slate or Forev, Co<inlry)
Year
520-48-2321 (Yea~)70
1943 BiRings, MT

0:
~
CJ
W
~
0
Penrose Main Hospital
1 oa. DECEDENT'SUSUAL OCCUPATION~ 1<n1 of WOt1< Ch
done <1Jriogmos of "°'1<inQlite. Do
Accoontant
13o. RESIDENCE· STATE
CO
3b. CClUN'TY

El Paso
use f9lired)
Accounting
3c. CFTY, )'OWN. OR
.
Cokl(ado.SprillQ1l
lClCA!lON ---
§ -- 0--
11.MARUII..SW\JS

3d.STIET~~
oa-cecs
983Tenderfoo1Hi11Road#8
112.SPOUSE (llwilo, givemaidooname)

27c. NAMEANOCOUHTY
Dawn Miller El Paso
28. NAME-OFATTEIONG PHYSICIANIF OTHER1liANSIGNlt,13PHYSICIAN

o-·- . .,,..,,,._)U,
QNocp<_but.,.._.'3...,..IOI
)Mfbololo-

Mar4,2016
DATE ISSUED
THIS IS A TRUE CERTIFICATION Of NAME AND FACTS AS
i:i)ff
KIRKA. SOL
RECORDED IN Tl-OS OFFICE. Do not accept uoless prepared on INTERIM STATE REGISTRAR
security paper with high resolution border displaying the Colorado state
seal and signature of the Registrar. PENALTY BYLAW, Section25-2-118,
Colorado Revised Statutes, 1982, if a person alters, uses, attempts to
use or furnishes to another for deceptive use any vital statistics record.
NOT VALID IF PHOTOCOPIED.
111111111111
* 007718375 *