After filing return to:
MICHAEL E. ROLOFF
11004 SW 37TH AVENUE
PORTLAND, OR 97219

AFFIDAVIT OF MAILING

I am over the age of 18 (eighteen) years, and, on _______________ (date), I mailed the letter dated March 8, 2003, re: ELVINA M. ROLOFF CERTIFICATE OF DEATH from DAVID S. VAN BEEK, c/o 11004 SW 37th Avenue, Portland, OR 97219, a copy of which is attached, to the addressee set forth below, by depositing a copy enclosed in a postpaid wrapper, in an official depository under the exclusive care and custody of the United States Postal Service, in Portland, Oregon addressed as follows: 

DR. DAVID A. SMITH, M.D.
SUITE 300
8614 EAST MILL PLAIN BLVD
VANCOUVER, WASHINGTON 98664

A copy or facsimile of this document shall have the same effect as the original.

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Signature                                                            Dated