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Ry 1, 2011 Decedent s last name First name Middle initial Social security number Address of decedent at time of death (number and street) Date of death City County of residence State ZIP code Mark an X if copy of death certificate is attached If the decedent was a nonresident of New York State on the date of death, mark an X in this box and attach completed Form ET 141, New York State Estate Tax Domicile Affidavit .

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