Name

Address

City

State

Zip

Email Address

Phone Number

How are you related to the decedent (the person who passed away)?

Have you been appointed as the personal representative or executor of the decedent's estate?
Yes
No

When did the decedent die?

What was the cause of death?

Was an autopsy conducted?
Yes
No

Was the decedent married or single?
Married
Single

Is the decedent a minor?
Yes
No

Did the decedent leave children?
Yes
No

Was the decedent employed at the time of death?
Yes
No

Were you dependent upon the decedent for financial support?
Yes
No

Were other family members dependent upon the decedent for financial support?
Yes
No

Do you have reason to believe the decedent experienced pain or suffering as a result of an incident that contributed to his/her death?
Yes
No

Did an accident occur which caused the death?
Yes
No

Is there any indication that the poor medical treatment contributed to cause the decedent's death?
Yes
No

Please note any other concerns: