Date (mm/dd/yy):
Given by:
Name:
Age:
Occupation:
Was he/she known by any other name? If so, what was this name?:
Last fixed address of the deceased:
Date of death (Day, Month, Year):
An Affidavit of Delay is necessary if death occurred 3 years or more before the instructions are given.
Is a certified copy of Death Certificate available?
YesNo
N.B. If not, efforts must be made to obtain one, or a copy of the Order for Burial (pink paper) must be submitted.
Did the deceased leave a will?
Address:
Funeral expenses=
N.B. Copies of documentary proof in support of this sum must be obtained, if available.
Mortgage loans and other personal debts=
(a) Realty: (Bare land or land with building(s) thereon):
(b) Personalty: (e.g. Bank Accounts, Insurance Policies, Motor Vehicles, Shares and Stocks, etc.) :
Which was the principal place of residence of the deceased
Which of the above mentioned items of Real Estate (if any) was used as the principal place of residence of the deceased and any other person(s) up to the date of his/her death?
For how many years was this property the principal place of residence?
Name & address of spouse
spouse is wife, husband, common law husband or common law wife who have resided exclusively together for at least 5 years prior to death
address:
Name, address and date of birth of all children
Name & address of both parents
Name & address of all siblings
Did any relative die before the deceased?
yesno
If so, when and where?
We wish to assure you that only you and the lawyers at Archer Cummings & Company will have access to your information and your file at any time.
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