10
STATEMENT 'T
(i) Persons entilled in distribution under the intestacy or partial intestacy.
Maure
A
RelaBanship to the decessed
(ii) Personal representatives of such of the above as have died since the death of the deceased.
Name of pero tul representative
Name of the decensed
Date of depth of
Person represented
ach decessed person
(W) Beneficiaries under the will who survived deceased and have since died or who predeceased him/her but did not thereby lose their benefits.
Nike
AKS
Date of
dond
Name of permacul
Address of personal KEDVES CURL Eve
STATEMENT "V*
Part 1.
Name (including "toog" or family names) in which the deceased personally held property in the Colony.
Namo
How did be come by the Tourne Cele, mula de given to him, adopted by him, or did be succeed to 117)
For what purpowe wis tha
THLOVE KAREE
Part 21.
Name (including "tong" or family ames) other than those falling under Part 1, by virtue of which the deceased bad an interest in property in the Colony.
IN CH
None of the pestapti edild LO USE DOS THume; relationshelye to the decocted
Particulati 5T UNE operly
Extent of deceased's Inverer.
NOTE-The depocent 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 dame whatsoever,
Signature of deponent