State of New York Title No._______________
County of ________
I, _________________________, being duly sworn, depose and state the following to be true under the penalty of perjury:
1. I currently reside at:
2. I am the ____________ of _____________________ who died a resident of _______________ County, on the _______ day of _____________, 20_____.
3. ______________________ and ________________ were continuously married up to the time of his/her death and said marriage was not terminated by divorce, annulment or by a judicial decree of separation.
4. I make this statement knowing full well that __________________________, as policy issuing agents for Stewart Title Insurance Company relies on the accuracy thereof for the purposes of issuing its policy of title insurance free and clear of the aforesaid.
Sworn to before me this _____ day
of __________________, 20____.
No guidelines are available for this form at this time.