10
STATEMENT 'Y'
(i) Persons potilled in distribution under the intestacy or partial intestacy.
Harpe
Belkomlig do the deceased
(ii) Personal representatives of auch of the above as have died since the death of the deceased.
Name of personal
ine protektas taalvę
Address
Name of the desperad person represented
Date of depth of
ach decessed perian
(ü) Beneficiaries under the will who survived deceased and have since died or who predeceased him/her but did not thereby lose their benefits.
Notr
Date of death
Name of pemanal
Address of personal representative
STATEMENT "Y"
Et
Part 1.
Name (including "tong" or family names) in which the deceased personally held property in the Colony.
NARIA
How did he came by the mugs Če.e. ma da given to him, adopted by him, or did for moriteedi ter 1077
For what purpose ikka to CHLOVE KNEE
Part 1.
Name (including "tong" or family pames) other than those falling under Part 1, by virtue of which the deceased bad an interest in property in the Colony.
N
Name of the pestspil, edlikukodi. to use the nume; relatia cuchil
to the deced
Particulati of Ube
propert
Blent of
deceased's Joverex
Nor-The deponent is required to sign the following certificate.
1 certify that, save as appears from the above Statement, the deceased to the best of my knowledge and belief held no property in this Colony under any family or "tong" name; nor had the deceased any interest in any property in this Colony held under any family or "tong" name or under any name whatsoever,
Signature of deponent