STATE OF ILLINOIS St. Clair County ) ) ) SS. ) PROOF OF DEATH __________________________________________ being duly sworn, deposes and says that ___________________________________________________________, late of the __________ of______________________, in the County of St. Clair and State of Illinois, departed this life at ___________________________, in said County, on or about the ________________day of _________________________________________, 20_____, and that ___________died leaving __________ Last W ill and Testam ent to the best of ________________ knowledge and belief and that __________died, aged_________years,_________, months,_______ days. ____________________________________ Subscribed and sworn to before this ________ day of _____________, AD 20_______. KAHALA DIXON, Circuit Clerk By: ________________________________Deputy 3 American LegalNet, Inc. www.FormsWorkflow.com