Recording Transmittal 2-6-08
CITY OF CHANHASSEN
PLANNING DEPARTMENT
7700 Market Boulevard
P.O. Box 147
CHANHASSEN, MN 55317
(952) 227-1100 FAX (952) 227-1110
LETTER OF TRANSMITTAL
DATE I JOB NO.
2/6/08 07-21
ATTENTION
Sue Nelson
RE:
Document RecordinQ
TO: Campbell Knutson, PA
317 Eagandale Office Center
1380 Corporate Center Curve
Eagan, MN 55121
WE ARE SENDING YOU
[8J Attached D Under separate cover via the following items:
D Shop drawings
D Copy of letter
D Prints
. D Change Order
D Plans D Samples D Specifications
D Pay Request D _
COPIES DATE NO. DESCRIPTION
1 Affidavit of Identity and Survivorship (Harley E. Bergren)
1 Elizabeth Berqren Certificate of Death (certified copy)
THESE ARE TRANSMITTED as checked below:
D For approval
D For your use
D As requested
D Approved as submitted
D Approved as noted
D Resubmit copies for approval
D Submit copies for distribution
D Returned for corrections
D Return corrected prints
D For review and comment [8] For Recording
D FOR BIDS DUE D PRINTS RETURNED AFTER LOAN TO US
REMARKS Sue - Per your email these documents were required in order to record Site Plan Agreement 07-21 which is
already in your possession.
COpy TO:
If enclosures are not as noted, kindly notify us at once.
Meuwissen, Kim
From:
Sent:
To:
Sue Nelson [SNelson@ck-law.com]
Wednesday, January 23,2008 11 :35 AM
Meuwissen, Kim
Subject: MORE RECORDING PROBLEMS -- SITE PLAN PERMIT #07-21/ POWER SYSTEMS (Harley E. Bergren
Property)
Kim,
My mistake on this one -- since this is torrens property and they are more particular than the abstract department, in order to
effectively give clear title to Harley E. Bergren for this property since the passing of his wife, we will need to file with the Registrar
of Titles Office the attached Affidavit of Identity & Survivorship with a CERTIFIED COpy of the Certificate of Death attached.
Please have the attached Affidavit signed by Mr. Bergren in front of a notary, have him attached a certified copy of the death
certificate to it, and return the original to me for filing simultaneously with Site Plan Permit #07-21.
Susan ~ lJ.{fr.son
Legal Assistant
CAMPBELL KNUTSON, P.A.
317 Eagandale Office Center
1380 Corporate Center Curve
Eagan, Minnesota 55121
Direct Dial: (651) 234-6222
Office Phone: (651) 452-5000
Fax: (651) 452-5550
Email: ~m~-.-?9n@Gk:l(lw.com
2/6/2008
[Reservedfor Recording Data)
AFFIDA VIT OF IDENTITY AND SURVIVORSHIP
STATE OF MINNESOTA)
( ss.
COUNTY OF )
. NAME OF DECEDENT:
Elizabeth L. Bergren
I, Harley E. Bergren, residing at 8104 Highwood Drive, Apt. #0108,
Bloomington, Minnesota 55438-1087, being first duly sworn on oath, states from
personal knowledge:
That the above named Decedent is the person named in the certified copy of
Certificate of Death attached hereto and made a part hereof.
That said Decedent on date of death was an owner as a joint tenant of the land
legally described as follows:
Lot 4, Block 1, CHANHASSEN BUSINESS CENTER 2ND
ADDITION, according to the recorded plat thereof, Carver County,
Minnesota
as shown by instrument recorded November 20, 1995 as Document No. T89854 in the
office of the County Registrar of Titles of Carver County, Minnesota, as evidenced by
Certificate of Title No. 25058.0.
That the name of the surviving joint tenant is Harley E. Bergren.
136645
1
Subscribed and sworn to before me this
3 I $1"" day of Jc.\ V\ Lt ct-("~ ,2008.
by Harley E. Bergren.
t
.ptvuu ~
Notary Public
THIS INSTRUMENT WAS DRAFTED
BY:
CAMPBELL KNUTSON
Professional Association
317 Eagandale Office Center
1380 Corporate Center Curve
Eagan, MN 55121
Telephone: (651) 452-5000
SRN
136645
AFFIANT:
I~/~
HAR~EROREN \
-
8" DEBRA L. SINCLAIR
. ............... NOTARY PUBLIC. MINNESOTA
'. \ MY COMMISSION
, . EXPIReS JAN. 31, 2012
~
(Notary Seal)
Tax Statements for the real property
described in this instrument should be
sent to:
Harley E. Bergren
8104 Highwood Drive, Apt. 0108
Bloomington, MN 55438-1087
2
local Rle Number
1 a Name of Deceased. First
ELIZABETH
1b Alias
5 Date of Birth
0 Februar 28, 1915
\r) Sa Father's Name (first, middle)
Edward
CD rJ 10 Race
ro White
0
J 13a Marital Status
X Mar. Dlv. Wid. Never Mar.
15 Kind of Business or Industry
Power System
17c City or Township of Residence
Edina
MINNESOTA DEPARTMEt-lT OF HEAlTH
Section of Vital Statistics
CERTIFICATE OF DEATH
Acel 7~': ..Z/il;2!;!~L~:50
TYPE, . . {..rf.Jn 0" ,
-~-~U~-
555IN!T. YI
State 'File'NuUrii5er' ..~ . '
Suffix
TypelPrint
In Pennanent
Black Ink
Middle last
L YOIA
BERGREN
17e Residence in City or Township
X City Umits Township limits
19a ,Place of Death (specify one)
Hos. X N.H. Res. Other -+
19c Name of Facifity Where Death Occurred 01 not institution, specify street address)
Jones Harrison Residence
20a Name of Informant
Harley E. Bergren
21 Method of Oisposition (check all that apply)
2 Social Security No. 3 Sex 4 Date of Death
508-26-5115 Female February 23, 2001
6a Age (In years) 6d ~nder 168 minutes 7 Place 01 Birth (city and slate/foreign country)
85 Raymond, Nebraska
: Sb Father's last Name 9 Mother's Name (first, middle, maiden surname)
: Riddell Abi ail Steele
11a Hispanic Origin '11b If Yes, Specify Cuban, Mexican etc.., 12 Oecedenfs Education
: ' 12a PrimaJYlSecondary (0-12) 12b CoOege (1-4, 5<-)
X No Yes -.: 5
13b Name of Spouse [If wife, specify maiden name) 14 Decedenfs Usual Occupation
Harley E. Bergren Vice President
16 U.S. Veteran 17a Slate of Residence 17b County of Residence
X No Yes Minnesota Hennepin
17d Address of Decedent (number, street, zip)
3330 Edinborough Way #1611
18a City or Township of Death
Minneapolis
Specify
55435
1Sb County 01 Death
Hennepin
19b If Hospital (specify one)
In tient
ER
DOA
Other
20b Informant Is _ of the deceased (spouse, child, parent, sibling, etc.)
Husband
Specify
X Burial Cremation
23 Name of Cemetery
Dawn Valle Memorial Park
24 If Cremation, Specify Name of Crematory
Donation
Entombment
Other --..
22 Date of Disposition
February 26,2001
City State
Bloomington Minnesota
25 If Cremation, Specify Name of M.E.' Coroner Authorizing Cremation
26a Name of Funeral Establishment
: 26b license No: 27a Illnature of F:uneral Service licensee
I. ,~ (~.
576
I
~~I
:~~.
I
I
ANoI
Gea'rt':'Delmore.'Park Cha el .
29a Name of Person Certifying Cause of Death (please type)
r1.1 c..lffrt< D f4-.. I! ~ () It/-
29d Address of Certifier (street & number)
).001 tf ~
29b Titie (check one)
>0 M.D. Coroner' M.E.
2ge CitY
t1t
31 0 t SJ9ned 32 Slgnatu of R
31/0I'(}}i
Enter the diseases, Injuries, or COmplications that caused death. Do not enter the
shock or heart fanure. Ust only one cause per line.
~. N~ ~':~
~
30 Signature of M.D.' M.E 'Coroner' D.O.
. t< #'\0
34 PAR I I '
IMMEDIATE cause of death (final
disease or condition resulting in
death)
Sequentially list conditions, if any,
W leading to immediate cause. Enter b
~ UNDERLYING cause last, (disease .
I- or injury that initiated events
W resulting In death). . J.f1 ' ()
~ 35 I attended the deceased from ~ ~ ::f3 /:. 10
~ 36 PART II Other significant I.) .
0... conditions contributing to death LI.
but not resulting in the underlying
cause given In Part I. :r1 Was Female Pregnant At Death? Yes X- No Unknown In lasl12 Months?
39 MANNER OF DEATH ~a:Ural 40 M.EJCoroner Notilled 41 Autopsy 42 Were autopsy results avaDable
Yes XNo Yes ' .&No when filling In cause of death
44a Place of Injury (street & number, city' township, slate)
11/3/ () /
; I viewed the body alter death Yes
t... f)
f)~,
Yes
38 Tune of Death
10:10 p.m.
Yes
No
No Unknown
43 Diagnosis Deferred
Yes
MUST
BE
REFERRED
TO
M.E. or
CORONER
--Accident
_Homicide
_Suicide
_Pending lnves.
_Cannot be Del
Not Oassifiable
44b DescrIbe How Injury Occurred
44c Type of Place Where Injury Occurred
44d Date of Injury
44e Time of Injury
441 Injury at Worf<7
Yes No
/
STATE OF MINNESOTA
COUNTY OF HENNEPIN
CERTIFIED TO BE A TAUE AND
CORRECl" COpy OF THE ORIGINAL ON
FILE AND O~ RECORO IIJ MY OFFICE
MAR 0 6 2001
ct;0i11 ~
PATRICK H. O'CONNOR
DIRECTOR OF LICENSING