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REV-1737-1 OFFICIAL USE ONLY

a surviving spouse or member of the decedent’s family. 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. 1. Names and addresses of the decedent’s surviving spouse and members of his/her immediate family: Name and . R ...

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  Spouses, Surviving, Surviving spouse

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