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Rev 1737 2018-2023
Address Second Line of Address City State ZIP Code The following information is submitted in support of the statement that the above individual was not domiciled in the Commonwealth of Pennsylvania at the date of death. Names and addresses of the decedent s surviving spouse and members of his/her immediate family Name and Relationship to Decedent Street Address City/Borough Did the decedent ever live in Pennsylvania If yes during what periods o Yes o No What was the nature of decedent s place s...Show details
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