Affidavit of Heirship
State of ______________________ )
County of ____________________ )
I hereby certify and attest that I, __________________________________________, residing at
___________________________________________________________________________________,
am providing this affidavit to advise SUMMUM of a complete list of persons that would have rights in
determining the disposition of my body at the time of my death.
The undersigned hereby certifies that he/she would be survived by the following relatives (list all
relatives in the following priority: surviving spouse, children, parents, siblings, and other relatives):
Name
Address
Relationship
Age
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
(Add an additional sheet if needed to complete the list)
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