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Register of Wills of Butler County, Pennsylvania

AFFIDAVIT OF DEATH
Must Attach Original Death Certificate
Estate
No.
Social Security
No.

Deceased
A/k/a
Before the Register of Wills of said County
personally came
at
deposes & says

in said County, departed this life, at
A.D. 20
property estimated to be of the value of $
and the location of which is as follows:

age

who resides
, being duly sworn,
, a resident of
,

on the
day of
, about
o’clock
M., possessed of personal
, and possessed of real estate, the estimated value

That said decedent left a spouse – whose name and residence is
and the following as next of kin:
NAMES

RELATIONSHIP

RESIDENCE

That the above named are the spouse – and all the next of kin of said decedent, to the best of
knowledge and belief.
YOUR PETITIONER THEREFORE AVERS THAT LETTERS ARE NOT NECESSARY.

_______________________________________
Signature of Petitioner

Sworn and subscribed to before me this
day of

, 20

______________________________
Notary Pu