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HEIRSHIP AFFIDAVIT QUESTIOi\NAIRE

Name of Decedent: Date and Place of Death: Date and Place of Birth: Ever Manied ? _Yes
Spouse

_No.

If

yes, how many times ma:ried? Date and Place of Marriage:

#l:

Spouse

#l

Deceased?

_ Yes No

If

yes, date and place of death:

Yes No. date and place of birth If child is deceased and was married, list deceased child's spouse, and if spouse is deceased, list children, if any, on a separate sheet

Children of this marriage?

If "Yes, list each child by name,

Name

Deceased Yes
Date and Place of Birth

No No

Deceased
Name Date and Place of Birth

Yes Yes

Deceased
Name Date and Place of Birth

No

(List additional children on separate sheet)

Spouse #2:

Date and Place of Marriage:

Spouse #2Deceased?

_ Yes No
death:

If

yes, date and place

of
No.

Children of this marriage?

Yes

If "Yes, list each child by ntme, date and place of birth If child is deceased and was manied, list deceased child's spouse, and if spouse is deceased, list children, if any, on a
separate sheet

Date and Place of

Birth Birth Birth

_Deceased

Will:

_Yes_No
Yes

No

Name

Date and Place of

Deceased Yes Will: Yes

No
No

Date'nd Ptace of

List additonal children on separate sheet List additional spouse(s) and child(ren) on separate sheet.

Deceased Yes No Will:-Y". -No

Any children of Deceased not listed above?

Yes

No
Deceased

Name
List additional children on separate sheet

Date and Place of Birth

Name of Affiant: Relationship to Deceased:

Name of witness #1, how long known Decedent, relationship to Decedent:

Name of witness #2,how long known Decedent, relationship to Decedent: