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Ars, son of ________________________ residing at _____________________________________________________________ do hereby declare and state as follows: I knew the deceased __________________ who was a Parsi / other than Parsi by religion and who was residing at ____________________________________ for the last ______ years. He/She died on ________________ (give the date of death) at _____________ (give the place of death) leaving behind him / her the following heirs under the Indian Succession Ac.

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