Free affidavit of domicile 16Free affidavit of domicile 16
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Lackawanna County, Pennsylvania

__________________________, being duly sworn, deposes and says
as follows: My address is _____________________________ State of
__________________, I am executor/administrator, of the estate of
_______________________or surviving tenant of the joint tenancy between
myself and _______________________(deceased) who died on the _____
day of _______20____, being duly sworn, deposed and says as follows:
I am an executive officer, namely:______________ of ________________
A corporation duly organized under the laws of the State of Pennsylvania,
having its principal place of business at __________________which is the
executor/administrator _____________________of the estate of
_______________________, deceased who died on the ____day of
_____,20__. At the time of death the decedent, the physical status of
_____________shares of __________________________ a Corporation
were located in the City of _________________, County of ___________,