Form FT-1
Grandparents Aunts and Uncles First Cousins **First Cousins Once Removed
# #
(___)_________________ (___)____________________
________________________ (___)_________________ (___)____________________
(___)_________________ (___)____________________
(___)____________________
(___)_________________ (___)____________________
________________________ (___)_________________ (___)____________________
(___)_________________ (___)____________________
(___)____________________
_____________________ (___)_________________ (___)____________________
Paternal Grandfather ________________________ (___)_________________ (___)____________________
(___)_________________ (___)____________________
_____________________ ________________________ (___)____________________
Paternal Grandmother Father of Decedent
(___)_________________ (___)____________________
________________________ (___)_________________ (___)____________________
(___)_________________ (___)____________________
(___)____________________
(___)_________________ (___)____________________
________________________ (___)_________________ (___)____________________
(___)_________________ (___)____________________
(___)____________________
____________________ (___)_________________ (___)____________________
Maternal Grandfather ________________________ (___)_________________ (___)____________________
(___)_________________ (___)____________________
____________________ ________________________ (___)____________________
Maternal Grandmother Mother of Decedent
STATE OF NEW YORK
COUNTY OF
_______________________________ being duly sworn, states that the charts contained on this paper are correct.
___________________________________________
Sworn to before me on _____________________
________________________________________ **List First Cousins Once Removed by # that corresponds
NOTARY PUBLIC with deceased first cousin.