Docket No.: ______________ Essex County Surrogate's Court THEODORE N. STEPHENS, II SURROGATE Hall of Records, Room 206 Newark, New Jersey 07102 Phone 973-621-4900 Fax 973-621-2647 DEVERO D. MCDOUGAL DEPUTY SURROGATE State of New Jersey In the matter of the Estate of: ____________________________, Deceased AKA: State of New Jersey } ss County of Essex CONSENT TO SEAL DEATH CERTIFICATE Because of the personal information present on a death certificate and the prevalence of identity theft regarding recently deceased persons, I __________________________________________, the ________executor ________administrator ________surviving spouse or domestic partner ________authorized next of kin hereby direct that the decedent's death certificate be sealed by the Surrogate Court of Essex County, New Jersey. ___________________________ Signature Subscribed and sworn to before me this day of , 20 . _______________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com