NORTH CAROLINA
AFFIDAVIT OF DEATH

I, [Your Name], being duly sworn, depose and state as follows:

Statement of Facts

1. I affirm that I am of legal age and competent to make this affidavit.

2. I am the [Relationship to Deceased] of [Deceased's Name], having firsthand knowledge of the matters herein.

3. [Deceased's Name], known to me personally, ceased to live on [Date of Death], in the city of [City Name], County of [County Name], State of North Carolina.

4. The passing of [Deceased's Name] is officially documented in the records of the North Carolina Department of Health and Human Services.

5. The Social Security Number of [Deceased's Name] is [Social Security Number].

6. Enclosed herewith is a certified copy of the death certificate issued for [Deceased's Name] by the appropriate authorities.

Sworn Oath

I affirm under penalty of perjury that the foregoing statements in this affidavit are true and correct to the best of my knowledge and belief.

Signature

[Your Name]
Affiant

Subscribed and sworn to before me this [Day] day of [Month], [Year].

[Notary Public's Name]

Notary Public for the State of North Carolina

My Commission Expires: [Expiry Date]

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