Affidavit of Death and Heirship

_____________________________________________
James Brenden Thigpen

Decedent’s name

Indicate N/A (Not Applicable) for any item that does not apply. SIGN IN THE PRESENCE OF A NOTARY
PUBLIC.

I, ________________________, of lawful age and under oath and penalty of fraud and perjury, hereby
Rene A. Champion

certify that all statements herein are true and correct, based on my knowledge of the above named decedent. If the
State makes payment based on the information herein, I will indemnify and hold harmless the State, its officers and
employees, from any other valid claims to unclaimed property.

That I was personally well acquainted with the decedent for ____ years and my relationship with the decedent
27

was that of ________________. That said decedent departed this life in the city of ________, county/parish of
his mother Gulfport

_____________, in the state of _______________, on or about ____________, 20___.

Harrison Mississippi May 29th

1. Did the decedent leave a Will? Yes No

If yes, was the will admitted to probate? Yes No

If yes, where and when? _______________________________________________________________

2. Was an administrator or executor appointed for the estate? Yes No

If yes, give the name and address of administrator/executor. ___________________________________

____________________________________________________________________________________

If yes, have the estate proceedings been closed? Yes No

3. List each person to whom the decedent was married during his/her lifetime.

Name of Date of Address or Date If Divorced Give Date

Spouse Marriage of Death
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

4. List each child born to the decedent during his/her lifetime, including illegitimate children.
Name of Date of Address or Date Name of Other
Child Birth of Death Parent
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
 5. List all adopted children of the decedent.

Name of Date of Address or Date Name of Other

Child Birth of Death Parent

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
6. List all children of any deceased son or daughter of the decedent, including adopted children.

Name of Date of Address or Date Name of Child’s

Grandchild Birth of Death Parents

________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
NOTE: IF THE DECEDENT LEFT SURVIVING CHILDREN OR GRANDCHILDREN, DO NOT COMPLETE QUESTIONS 7
THROUGH 10 BELOW.

7. Give the name of the decedent’s father and address, if living, or list date and place of death.

____________________________________________________________________________________

8. List each of the decedent’s father’s children.

Name of Date of Address or Date Name of Child’s

Father’s Child Birth of Death Spouse

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

9. Give the name of the decedent’s mother and address, if living, or list date and place of death.

____________________________________________________________________________________

10. List each of the decedent’s mother’s children.

Name of Date of Address or Date Name of Child’s

Mother’s Child Birth of Death Spouse

____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

________________________________________________________
Signature of Person Making Affidavit
State of ___________________ County of ________________ City of _________________

Subscribed and sworn to before me this ______ day of __________, 20____.

My Commission expires: ________________ ____________________________________________

Notary Public