Wrongful Death Inquiry Form - The Burkhalter Law Firm

Todays Date *

Name *

First

Last

Address (Street, City, State, & Zip Code) *

Email *

Contact Phone Number *

When is the best time to contact you, and how would you prefer we contact you?

Name of deceased.

Your relationship to the deceased.

Age of deceased.

Date of incident.

Location of incident.

Describe the circumstances which resulted in the death.

Who are the responsible parties (who are you complaining against) and why do you believe they are responsible?

What was the cause of death as listed on the death certificate?

Was there an autopsy? yes or no

If so, do you have the results? yes or no

Was there any estate? yes or no

If so, where and who the administrator/administratrix?

Other pertinent information:

Any other facts you would like us to know?

Do you have questions or concerns?

How did you hear about us?

Name