I, , being duly sworn, depose and say:
1. That I am the of , deceased, who died on the day of , .
2. That at the time of death, the domicile (legal residence) of said decedent was:
3. That the decedent had resided at the above address for years immediately prior to death.
4. That this affidavit is made for the purpose of securing the transfer or delivery of property owned by the decedent at the time of death.