Name

Email Address

Phone Number

How are you related to the decedent?

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

Does anyone have power of attorney over the decedent?
Yes  No 

When did the decedent expire?

What was the cause of death?

Was an autopsy conducted?
Yes  No 

Has the funeral been held?
Yes  No 

Has the decedent been buried/cremated?
Yes  No 

Who paid the funeral bill?

How?

Was the decedent married or single?
Married  Single 

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

Were you 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 

For how long?

Did the decedent leave children?
Yes  No 

Is the decedent a minor?
Yes  No 

Did an accident occur which caused the death?
Yes  No 

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