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' Required if the decedent (the person who (New York State Bar Association)

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' Required if the decedent (the person who died) has only one distributee (heir) or if the distributees are
grandparents, aunts-uncles, or cousins. Must be completed by a person who knows decedent’s family tree, has
no financial interest, and is not the only distributee, or the only distributee’s spouse or child (UR 207.16[c]).
' Complete only as much of the form as required. If there are no relatives in a section, write “None.”
' If a person’s date of death is unknown, indicate whether that person died before the decedent
(by writing “predeceased”) or died after the decedent (by writing “post-deceased”).
' If more space is needed, attach additional sheet(s). Sign on page 4 in front of a Notary Public.
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF NEW YORK
X
PROCEEDING FOR FAMILY TREE
Estate of AFFIDAVIT
a/k/a
Deceased File No.
X
STATE OF )
COUNTY OF )
I,
, BEING DULY
SWORN, DEPOSE AND SAY:
I AM
OVER THE AGE OF
18 AND RESIDE AT:
MY
RELATIONSHIP
TO
THE
DECEDENT IS
(examples:
cousin, family
friend, clergyperson, etc.):
I KNEW THE DECEDENT FOR YEARS, AND MY KNOWLEDGE OF HIS/HER FAMILY TREE IS
BASED ON (examples: conversations with decedent or decedent’s family, visits, etc.):
1. a) DECEDENT’S MARRIAGES (name most recent spouses first): ' Decedent was never married [ ].
SURVIVING SPOUSE: ' Surviving spouse died after decedent [ ].
EX-SPOUSE: [ ] divorced or [ ] died while married to decedent.
EX-SPOUSE: [ ] divorced or [ ] died while married to decedent.
b) DECEDENT’S CHILDREN (include non-marital children [born out of wedlock] and adopted children):
NAME: DATE OF DEATH (if deceased):
- 1 -
(1/19)
c) DECEDENT’S GRANDCHILDREN AND THEIR ABOVE-NAMED PARENT:
NAME: CHILD OF: DATE OF DEATH (if deceased):
d) DECEDENT’S GREAT GRANDCHILDREN AND THEIR ABOVE-NAMED PARENT:
NAME: CHILD OF: DATE OF DEATH (if deceased):
STOP. Go to (2) only if no one is listed above, everyone listed above died before (predeceased) the decedent
or all “Decedent’s Children” listed above are non-marital children (born out of wedlock) of a male decedent.
2. DECEDENT’S PARENTS: DATE O F DEATH (if deceased):
MOTHER:
FATHER:
STOP. Go to (3) only if both parents died before (predeceased) the decedent.
3. a) DECEDENT’S BROTHERS AND SISTERS (include half-brothers and half-sisters):
NAME: DATE OF DEATH (if deceased):
b) DECEDENT’S NIECES AND NEPHEWS AND THEIR ABOVE-NAMED PARENT:
NAME: CHILD OF: DATE OF DEATH (if deceased):
- 2 -
c) DECEDENT’S GRANDNIECES AND GRANDNEPHEWS AND THEIR ABOVE-NAMED PARENT:
NAME: CHILD OF: DATE OF DEATH (if deceased):
STOP. Go to (4) and (5) only if everyone listed above died before (predeceased) the decedent.
4. a) DECEDENT’S MATERNAL GRANDPARENTS (mother’s side of family): DATE OF DEATH (if deceased):
GRANDMOTHER:
GRANDFATHER:
b) DECEDENT’S MATERNAL AUNTS AND UNCLES:
NAME: DATE OF DEATH (if deceased):
c) DECEDENT’S MATERNAL FIRST COUSINS AND THEIR ABOVE-NAMED PARENT:
NAME: CHILD OF: DATE OF DEATH (if deceased):
- 3 -
5. a) DECEDENT’S PATERNAL GRANDPARENTS (father’s side of family): DATE OF DEATH (if deceased):
GRANDMOTHER:
GRANDFATHER:
b) DECEDENT’S PATERNAL AUNTS AND UNCLES:
NAME: DATE OF DEATH (if deceased):
c) DECEDENT’S PATERNAL FIRST COUSINS AND THEIR ABOVE-NAMED PARENT:
NAME: CHILD OF: DATE OF DEATH (if deceased):
If everyone listed above predeceased the decedent, list any first cousins once removed (children of predeceased
first cousins) who survived the decedent and their above-named parent on a separate sheet (see EPTL 4-1.1[a][6],[7]).
THERE ARE NO OTHER PERSONS WHOSE DEGREE OF RELATIONSHIP TO THE DECEDENT IS THE
SAME AS, OR NEARER TO, THE PERSONS NAMED ABOVE.
Signature:
Sworn to before me on
, 20 Print Name
Notary Public
My Commission Expires:
(Affix Notary Stamp or Seal)
- 4 -
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' Required if the decedent (the person who (New York State Bar Association)

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Completed 23 September 2020

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