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Register of Wills of Chester County, Pennsylvania

UNDER 20 Pa.C.S.A. §925

File No. 15-

also known as

Social Security No.

I, ___________________________________________________________, an Interested Party, being duly sworn
(name of Affiant)

according to law, deposes and says:
1. I am an interested party in the estate of __________________________________________________________.
(name of Decedent)

My interest is _______________________________________________________________________________.
2. I have reviewed the public records, loan documents, and other available information and determined that
________________________________________, died on _______________________________.
(name of Decedent)

(date of death)

3.Decedent resided at ____________________________________________________________ prior to death.
(Decedent’s residence)

4. Based upon information and belief, Decedent was ________ years old at the time of death.
5. The instant Certificate