Commonwealth of Massachusetts

County of [County Name]

Introduction:

I, [YOUR NAME], residing at [YOUR ADDRESS], being duly sworn, declare under penalty of perjury that the information provided herein is true and correct to the best of my knowledge and belief.

Statement of Facts:

1. The Decedent, [Deceased's Name], born on [Date of Birth], passed away on [Date of Death].

2. At the time of death, the Decedent resided at [Deceased's Address], County of [County Name], Commonwealth of Massachusetts.

3. I am the [Relationship to the Deceased] of the Decedent and have personal knowledge of the facts stated herein.

4. Attached hereto is a certified copy of the Decedent's death certificate as Exhibit A, which serves as conclusive evidence of the Decedent's death.

Purpose of Affidavit:

This Affidavit is executed for the purpose of notifying government agencies and institutions of the Decedent's death to update records, terminate services, or claim benefits as may be required by law or policy.

Legal Assertions:

I hereby assert that the Decedent's estate is being administered in accordance with the laws of the Commonwealth of Massachusetts, and this Affidavit is made to facilitate the necessary legal and administrative actions following the Decedent's death.

Closing:

I understand that this Affidavit is executed under the laws of the Commonwealth of Massachusetts and that false statements made herein are subject to penalties under state law.

Signature:

[YOUR NAME]

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

[NOTARY PUBLIC NAME]

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