Preview
ELECTRONICALLY FILED
Drew County Circuit Court - Probate Division
Stephanie Chisom, Drew County Clerk
* FL
2024-] an-30 08:42:25
j ire, 22PR-24-8
C10D04 : 6 Pages
STEPHANIE CHISOM
COUNTY oe ON CLERK
BY
TIMI 'M
IN THE CIRCUIT COURT OF DREW COUNTY, ARKANSAS
IN THE MATTER OF THE ESTATE
OF CONNIE WY CLEMENTE, DECEASED no._22P@- 24%
AFFIDAVIT FOR COLLECTION OF SMALL ESTATE BY DISTRIBUTEE
Comes Michael Hui and, for the purpose of dispensing with administration of the estate of
Connie Wy Clemente, deceased, states on oath:
1 The decedent, Connie Wy Clemente, aged 68 years, who resided at 110 E. Willis
Street, Monticello, AR 71655, Drew County, Arkansas, died at Aurora St. Luke’s Medical Center,
2900 W. Oklahoma Avenue, Milwaukee, Wisconsin, on September 8. 2018. No petition for the
appointment of a personal representative for the decedent's estate is pending or has been granted.
2.2 More than forty-five (45) days have elapsed since the death of the decedent.
3 The value, less encumbrances, of all property owned by the decedent at the time of
death, excluding the homestead of and statutory allowances for the benefit of the surviving spouse
or minor children, if any, of the decedent, does not exceed $100,000.
4 There are no unpaid claims or demands against the decedent or his/her estate, and the
Department of Human Services furnished no federal or state benefits to the decedent (or, if such
benefits have been furnished, the Department of Human Services has been reimbursed in accordance
with state and federal laws and regulations).
5 An itemized description and separate valuation of each item of property of the
decedent, including the homestead, if any, and the names and addresses of the persons having
possession thereof, are as follows:
Description of Property Valuation Less In Possession of:
and Extent of Details of Encumbrances:
Encumbrances, If Any:
Franklin Templeton Account Approximately $20,305.77 Franklin Templeton
XXX-XXXXXX7135 PO Box 997151
Sacramento, CA 95899-7151
6. The names, ages, relationships to the decedent, and residence addresses of the
persons entitled to receive the property of the decedent as surviving spouse, heirs, or devisees of
the decedent's Will are:
Name Age Relationship Residence Address
Michael Hui Adult Brother 79 Sologne Circle
Little Rock, AR 72223-8913
Renato Clemente Adult Husband 8029 West Winfield Ave.
Milwaukee, WI 53218
Ellen Hui Adult Mother 110 E. Willis St.
Monticello, AR 71655
THEREFORE, the distributees of this estate shall be entitled to distribution of the property
identified above, without the necessity of an order of the Court or other proceeding, upon
furnishing a copy of this Affidavit, certified by the clerk, to any person owing any money, having
custody of any property, or acting as registrar or transfer agent of any evidence of interest,
indebtedness, property, or right of the decedent.
DATED this 24 day of Jupu > 2024
Coy Qe i °
Affiant
VERI (ON
STATE OF ARKANSAS)
COUNTY OF owe _)
1, Mufeedlns. Affiant herein, state on oath that the information contained in the
foregoing Affidavit for Collection of Small Estate is true and correct to the best of my knowledge,
information and belief.
Affiant
ACKNOWLEDGMENT
STATE OF ARKANSAS)
COUNTY OF \
On this the a day of : AWG A 2024 before me, the undersigned officer,
personally appeared M\U\acl_ Hu known to me or satisfactorily proven to be the
person whose name is subscribed to the within instrument and acknowledged that he/she
executed the same for the purposes and consideration therein contained.
In witness whereof I hereunto set my hand and official seal.
Noe Dawut'e—= 7
Notary Public
My commission expires: a a% 202
DANIELLE DAVE
NPORT
Notary Public -Ark ansas
Saline County
My Commission Expires 02-23-2026
Commission # 12696785
CERTIFICATE OF CLERK
The undersigned Probate Clerk of the Circuit Court of Drew County, Arkansas, certifies
that the foregoing is a true copy of an affidavit filed in this Court on the 0+" day of
JONUA! . 2024, that the same remains on file; and that no petition for the appointment of a
personal representative of the estate described in the caption has been filed in this Court,
DATED this 20 day of Jonuan4 _ 2024
May,
Wy
K3uq
Sei huphonve- Chi Clerk
Vie,
By LetDeputyOlen Gone
ms
ADie <=
= Clerk
©
Lungo?>
vine wouUnonT
DEPARTMI IEALTH SERVICE‘ ve: STATE FILE Dy SEPTEMBER 13, 2018
ORIGINAL.CER’ ICATE OF DEA’ STATE FILE NUM Re 2018036617,
71 OF DEATH
T. DEGEDENT'S NAME, 280g al; sar aa ‘3. DATE.RI ROUNTED DEAD
wei
oll
Mice Last f a
mM iBora
CONNIE CLEMENTE “SEPTEMBER 08, 2018
4. TIME PRONOUNCED DEAD (24hr) DATE iH. = VILLAGE, OR TOWNSHIP OF DEATH ‘9, COUNTY
OF Di
68 YEARS SEPTEMBER 19, 1949 FEMALE MILWAUKEE (CITY) MILWAUKEE
17, FACILITY NAN AND ADRESS
"HOSPITAL: INPATIENT
12. RESIDENCE ADDI
F LUKES MEDICAL CENTER}! 12800
ish Tee
W OKLAHOMAAWE an
18: RESIDENCE CITY, VILLAGE, OR TOWNSHIP, 14, RESID! {COUT 16, RESIDENCE STATE
8029 WEST WINFIELD AVENUE ‘st MILWAUKEE (CITY) _, MILW KEE! WISCONS! "
18. MARITAL STATUS: 17. WI DOMESTIC PARTNERSHIP 78, SURVIVING SPOUSE'S BIRTH NAME 20. DECEDENTS BIRTH LAST NAME
i. FATHER'S BIRTH NAME
ENATO CLEMENTE
MOTHER'S BIRTH NAME
"TENNESSEE
2
TAYL! WY EI EW.
23. INFORMANTS NAME t ING ADORE:
ATO CLEMENTE 73029 WEST
WE WINFIELD AVENUE, MILWAUKEE, WI 53216,
ig AND ADDRESS OF FUNERAL F/ 728. FUNERAL DIRECTOR: 27 DATES Nes
PELAGIC FUNERAL HOME, 3639 Wh HAMPTON AVE, MILWAUKEE, WI 53218 JELACIC, THOMAS M iy SEPTEMBER 13, 2018
26. TVPE OF MEDICAL CERTIFIER (25, MEDICAL CERTIFIER'S NAME AND TITLE i he LartaTES
-PHY: ADAM SCHLICHTING, MD i t EPTEMBER 14, 2018
id 31, DATE OF DEATH 5. TIME OF DEATH (24h) ‘33. MEDICAL CERTIFIER'S MAILING ADDRESS
SEPTEMBER 08, 2018 02:03 2901 WEST KINNICKINNIC RIVER PARKWAY, MILWAU! Re , WI 53215
EXTENDED FACT OF DEATH “ a
[34, USUAL OCCUPA’ 5. KIND OF BUSINESS/INDUSTRY ‘36. EVER IN US ARMED FORCES | 37. DECEDENT TRIDAU MEMBER
MEMBER REPRESENTATIVE LANDMARK CREDIT UNION TRIBE NAME(S)
[36 MANNER OF DEATH 39, METHOD OF DISPOSITION [a0_ PLAGE AND LOCATION OF DISPOSITI
CREMATION FOREST HOME CEMETERY, MILWAUKEE, WISCO
0
NSiN
/44. PART. Tha conditions tisted ara tha diseases, injuries, or complications that caused deaih. Condilions leading to tha immediate cause ara listed sequantially and the underlying cause is listed last, Interval Between Onset and Death
inmedtacaus:(o) SEVERE ISCHEMIC ABS BOWEL DAYS
.
Duelo rasa ce of: (b)
Tha
‘Duv to oF as @ consequence of: (6) sy q
te
ue to oF as 2 consequenceof: (0) We
41, PART Il, OTHER SIGNIFICANT CONDITIONS contributing ian sl i 6
to daath but not resulting in the underlying cause given in Par | ACUTE HYPOXEMIC & HYPERCARBIC RESPIRATORY FAILURE; ESKD & SERS!
[42, AUTOPSY PERFORMED | 43, DATE OF INJURY ‘44 TIME OF INJURY (24h) “45. INJURY AT WORK 45, PLAGE OF INJURY
I Bey
'47, LOCATION OF INJURY a . fii a TY OF INJURY
i 48, 1F INJURY STATED ANYWHERE IN CAUSE GF DEATH (Parl lor Port Il, DESCRIBE HOW IT OCCURRED.
4 ti
ay 2637820 Sy
‘hh, Nj NO AMENDMENTS PRESENT i: oe
fl.
SO is » iy that thls document
coy i and correct remy 6a sty, y
te
4
facts on file with the Wisgons Records Oftice,; tf
i ah
aita - (%
Nh
KAREN MICHALSKI
CITY OF MILWAUKEE HEALTH DEPARTMENT 188 107 4 pate a ‘SEPTEMBER 18
as
SC A
aS a Ds Bee: by
Gu Dang
a
Preview
ELECTRONICALLY FILED Drew County Circuit Court - Probate Division Stephanie Chisom, Drew County Clerk * FL 2024-] an-30 08:42:25 j ire, 22PR-24-8 C10D04 : 6 Pages STEPHANIE CHISOM COUNTY oe ON CLERK BY TIMI 'M IN THE CIRCUIT COURT OF DREW COUNTY, ARKANSAS IN THE MATTER OF THE ESTATE OF CONNIE WY CLEMENTE, DECEASED no._22P@- 24% AFFIDAVIT FOR COLLECTION OF SMALL ESTATE BY DISTRIBUTEE Comes Michael Hui and, for the purpose of dispensing with administration of the estate of Connie Wy Clemente, deceased, states on oath: 1 The decedent, Connie Wy Clemente, aged 68 years, who resided at 110 E. Willis Street, Monticello, AR 71655, Drew County, Arkansas, died at Aurora St. Luke’s Medical Center, 2900 W. Oklahoma Avenue, Milwaukee, Wisconsin, on September 8. 2018. No petition for the appointment of a personal representative for the decedent's estate is pending or has been granted. 2.2 More than forty-five (45) days have elapsed since the death of the decedent. 3 The value, less encumbrances, of all property owned by the decedent at the time of death, excluding the homestead of and statutory allowances for the benefit of the surviving spouse or minor children, if any, of the decedent, does not exceed $100,000. 4 There are no unpaid claims or demands against the decedent or his/her estate, and the Department of Human Services furnished no federal or state benefits to the decedent (or, if such benefits have been furnished, the Department of Human Services has been reimbursed in accordance with state and federal laws and regulations). 5 An itemized description and separate valuation of each item of property of the decedent, including the homestead, if any, and the names and addresses of the persons having possession thereof, are as follows: Description of Property Valuation Less In Possession of: and Extent of Details of Encumbrances: Encumbrances, If Any: Franklin Templeton Account Approximately $20,305.77 Franklin Templeton XXX-XXXXXX7135 PO Box 997151 Sacramento, CA 95899-7151 6. The names, ages, relationships to the decedent, and residence addresses of the persons entitled to receive the property of the decedent as surviving spouse, heirs, or devisees of the decedent's Will are: Name Age Relationship Residence Address Michael Hui Adult Brother 79 Sologne Circle Little Rock, AR 72223-8913 Renato Clemente Adult Husband 8029 West Winfield Ave. Milwaukee, WI 53218 Ellen Hui Adult Mother 110 E. Willis St. Monticello, AR 71655 THEREFORE, the distributees of this estate shall be entitled to distribution of the property identified above, without the necessity of an order of the Court or other proceeding, upon furnishing a copy of this Affidavit, certified by the clerk, to any person owing any money, having custody of any property, or acting as registrar or transfer agent of any evidence of interest, indebtedness, property, or right of the decedent. DATED this 24 day of Jupu > 2024 Coy Qe i ° Affiant VERI (ON STATE OF ARKANSAS) COUNTY OF owe _) 1, Mufeedlns. Affiant herein, state on oath that the information contained in the foregoing Affidavit for Collection of Small Estate is true and correct to the best of my knowledge, information and belief. Affiant ACKNOWLEDGMENT STATE OF ARKANSAS) COUNTY OF \ On this the a day of : AWG A 2024 before me, the undersigned officer, personally appeared M\U\acl_ Hu known to me or satisfactorily proven to be the person whose name is subscribed to the within instrument and acknowledged that he/she executed the same for the purposes and consideration therein contained. In witness whereof I hereunto set my hand and official seal. Noe Dawut'e—= 7 Notary Public My commission expires: a a% 202 DANIELLE DAVE NPORT Notary Public -Ark ansas Saline County My Commission Expires 02-23-2026 Commission # 12696785 CERTIFICATE OF CLERK The undersigned Probate Clerk of the Circuit Court of Drew County, Arkansas, certifies that the foregoing is a true copy of an affidavit filed in this Court on the 0+" day of JONUA! . 2024, that the same remains on file; and that no petition for the appointment of a personal representative of the estate described in the caption has been filed in this Court, DATED this 20 day of Jonuan4 _ 2024 May, Wy K3uq Sei huphonve- Chi Clerk Vie, By LetDeputyOlen Gone ms ADie <= = Clerk © Lungo?> vine wouUnonT DEPARTMI IEALTH SERVICE‘ ve: STATE FILE Dy SEPTEMBER 13, 2018 ORIGINAL.CER’ ICATE OF DEA’ STATE FILE NUM Re 2018036617, 71 OF DEATH T. DEGEDENT'S NAME, 280g al; sar aa ‘3. DATE.RI ROUNTED DEAD wei oll Mice Last f a mM iBora CONNIE CLEMENTE “SEPTEMBER 08, 2018 4. TIME PRONOUNCED DEAD (24hr) DATE iH. = VILLAGE, OR TOWNSHIP OF DEATH ‘9, COUNTY OF Di 68 YEARS SEPTEMBER 19, 1949 FEMALE MILWAUKEE (CITY) MILWAUKEE 17, FACILITY NAN AND ADRESS "HOSPITAL: INPATIENT 12. RESIDENCE ADDI F LUKES MEDICAL CENTER}! 12800 ish Tee W OKLAHOMAAWE an 18: RESIDENCE CITY, VILLAGE, OR TOWNSHIP, 14, RESID! {COUT 16, RESIDENCE STATE 8029 WEST WINFIELD AVENUE ‘st MILWAUKEE (CITY) _, MILW KEE! WISCONS! " 18. MARITAL STATUS: 17. WI DOMESTIC PARTNERSHIP 78, SURVIVING SPOUSE'S BIRTH NAME 20. DECEDENTS BIRTH LAST NAME i. FATHER'S BIRTH NAME ENATO CLEMENTE MOTHER'S BIRTH NAME "TENNESSEE 2 TAYL! WY EI EW. 23. INFORMANTS NAME t ING ADORE: ATO CLEMENTE 73029 WEST WE WINFIELD AVENUE, MILWAUKEE, WI 53216, ig AND ADDRESS OF FUNERAL F/ 728. FUNERAL DIRECTOR: 27 DATES Nes PELAGIC FUNERAL HOME, 3639 Wh HAMPTON AVE, MILWAUKEE, WI 53218 JELACIC, THOMAS M iy SEPTEMBER 13, 2018 26. TVPE OF MEDICAL CERTIFIER (25, MEDICAL CERTIFIER'S NAME AND TITLE i he LartaTES -PHY: ADAM SCHLICHTING, MD i t EPTEMBER 14, 2018 id 31, DATE OF DEATH 5. TIME OF DEATH (24h) ‘33. MEDICAL CERTIFIER'S MAILING ADDRESS SEPTEMBER 08, 2018 02:03 2901 WEST KINNICKINNIC RIVER PARKWAY, MILWAU! Re , WI 53215 EXTENDED FACT OF DEATH “ a [34, USUAL OCCUPA’ 5. KIND OF BUSINESS/INDUSTRY ‘36. EVER IN US ARMED FORCES | 37. DECEDENT TRIDAU MEMBER MEMBER REPRESENTATIVE LANDMARK CREDIT UNION TRIBE NAME(S) [36 MANNER OF DEATH 39, METHOD OF DISPOSITION [a0_ PLAGE AND LOCATION OF DISPOSITI CREMATION FOREST HOME CEMETERY, MILWAUKEE, WISCO 0 NSiN /44. PART. Tha conditions tisted ara tha diseases, injuries, or complications that caused deaih. Condilions leading to tha immediate cause ara listed sequantially and the underlying cause is listed last, Interval Between Onset and Death inmedtacaus:(o) SEVERE ISCHEMIC ABS BOWEL DAYS . Duelo rasa ce of: (b) Tha ‘Duv to oF as @ consequence of: (6) sy q te ue to oF as 2 consequenceof: (0) We 41, PART Il, OTHER SIGNIFICANT CONDITIONS contributing ian sl i 6 to daath but not resulting in the underlying cause given in Par | ACUTE HYPOXEMIC & HYPERCARBIC RESPIRATORY FAILURE; ESKD & SERS! [42, AUTOPSY PERFORMED | 43, DATE OF INJURY ‘44 TIME OF INJURY (24h) “45. INJURY AT WORK 45, PLAGE OF INJURY I Bey '47, LOCATION OF INJURY a . fii a TY OF INJURY i 48, 1F INJURY STATED ANYWHERE IN CAUSE GF DEATH (Parl lor Port Il, DESCRIBE HOW IT OCCURRED. 4 ti ay 2637820 Sy ‘hh, Nj NO AMENDMENTS PRESENT i: oe fl. SO is » iy that thls document coy i and correct remy 6a sty, y te 4 facts on file with the Wisgons Records Oftice,; tf i ah aita - (% Nh KAREN MICHALSKI CITY OF MILWAUKEE HEALTH DEPARTMENT 188 107 4 pate a ‘SEPTEMBER 18 as SC A aS a Ds Bee: by Gu Dang a