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Deceased) STATE OF NEW YORK COUNTY OF ) ) BEFORE ME, the undersigned authority, on this day personally appeared , ("AFFIANT") who is personally known to me (or, if not being personally known to me, did confirm his/her identity presenting as identification (i.e. drivers license #), and appearing to be fully competent and of sufficient age, upon being duly sworn, stated upon Affiant's oath the following: 1. M.

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