Affidavit of Death
STATE OF __________
COUNTY OF __________
I __________, residing at the following address __________, being of legal age, depose and say that:
The Decedent died on __________. At the time of death, the Decedent's legal residence was __________. Decedent lived at this residence for __________ year(s) prior to death and was not a resident of any other State within the United States of America at that time. Decedent's social security number is __________ .
The date of death is evidenced by a certified copy of the Certificate of Death, attached hereto.
That I am the successor to the estate of the decedent and to the decedents interest in funds held by various institutions and no other person has a superior right to the interest of the decedent in the described property;
That no proceeding is being or has been conducted in __________ for administration of the decedent's estate;
That the funeral expenses, expenses of last illness, and all unsecured debts of decedent have been paid.
Oath or Affirmation of Affiant:
I certify under penalty of perjury under __________ law that I know the contents of this Affidavit signed by me and that the statements are true and correct.
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Date
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STATE OF __________
COUNTY OF __________
On this _ _ _ _ day of _ _ _ _ _ _, _ _ _ _, before me, _ _ _ _ _ _ _ _ _ _ _ _, personally appeared __________, known to me (or satisfactorily proven) to be the persons whose name is subscribed to the within affidavit and being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing Affidavit subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge and belief.
In witness whereof I hereunto set my hand and official seal.
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Notary Public
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Title(and Rank)
My commission expires: _ _ _ _ _ _ _ _ _
