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Get IA DHS 470-4339 2010-2024

S No Date of Birth ___/___/___ SSN __________________ If no, Date of Death: ___/___/___ I CERTIFY UNDER PENALTY OF PERJURY AND PURSUANT TO THE LAWS OF THE STATE OF IOWA THAT THIS PAGE WAS COMPLETED CORRECTLY TO THE BEST OF MY KNOWLEDGE. Date Your Address Signature Print Name 470-4339 (Rev. 12/10) Your Phone Number Your relationship to the deceased .

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