CODICIL TO THE LAST WILL AND TESTAMENT

OF

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I, _________________________, of _________________________, _________________________, declare this to be the __________________ Codicil to my Last Will and Testament which was executed by me on __________________.

Except as expressly modified or changed by this Codicil, I approve, ratify and affirm my Will dated __________________.

I subscribe this my __________________ Codicil to Will on this _______ day of ______________, 19___.

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We, the undersigned, hereby certify that the above instrument, which consists of _____________ pages, including the page(s) which contain the witness signatures, was signed in our sight and presence by _________________________ (the "Testator"), who declared this instrument to be the __________________ Codicil to his/her Last Will and Testament and we, at the Testator's request and in the Testator's sight and presence, and in the sight and presence of each other, do hereby subscribe our names and addresses as witnesses on the date shown above.

Witness Signature: ________________________________________

Witness Name: _________________________

Witness Address: ___________________________________

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Witness Signature: ________________________________________

Witness Name: _________________________

Witness Address: ___________________________________

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Witness Signature: ________________________________________

Witness Name: _________________________

Witness Address: ___________________________________

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