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Victorville Satellite Office Open December 1st - 10th

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Public Administrator » Referral Form
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Your First Name:  
Your Last Name:  
Your Phone/EXT.  
Your Email:  
     
Reason for Referral:  
PG/Coroner Case #:  
COR/P.G. SUP. INIT/DATE:  

NOTE: Address Each Item: If Unknown, please indicate "UNK".
NAME OF DECEDENT: :  
AKA's:  
     
Date of Birth: (Format ## / ## / ####)  
Date of Death: (Format ## / ## / ####)  
SOC. SEC #:  
Marital Status:   SINGLE   MARRIED DIVORCED SEPARATED WIDOWED
     
If Widowed, Name of Spouse:  
DOD: (Format ## / ## / ####)  
Military Service:   Yes   No
If Yes, Which Branch:  
VA File or Claim #:  
Service #:  
STATUS OF DECEDENTS REMAINS: :  
Arrangements: Made By    Need to be Arranged
Remains Held At:  
   S.B. CO. Coroner Morgue
   Hospital/Facility
   Other
   Mortuary    Pre-Need: Yes No
   Cemetery    Pre-Need: Yes No
Is there a Will, Executor:     Phone:  
Willing to Act:   YES   NO   Location of Original Will:
     
Residence at Time of Death
Address:      APT#:
City:       State:     Zipcode:
Alternate Address or Post Office Box:  
Name of Mobile Home Park / Apartment Complex:  
Manager's First Name:  
Manager's Last Name:  
Manager's Phone Number:  
Private Residence:      Owned Rented Facility Other:  
Residence Searched:     YES NO    Photos Taken  YES NO  Copies Available
Items of Value in Residence or in Safekeeping:
FOUND:    Guns / Rifles    Address Book    Mail    Personal Paper  
     Will    Bills    Bibles    Photos    Lock-Boxes  
     Computer Equipment    Computer Disks or CD's  
     Large Items of Value   Nothing of Value  
    Other:     
     
Other Real Property:      YES NO    Mobile Home:   YES NO 
Address:    
Keys Held By:    
     
SIGNIFICANT OTHERS  
First Name:  
Last Name:  
Address:  
City:       State:
Relationship:       Phone/EXT.
Named In Will?:    YES     NO     UNK
     
FirstName:  
LastName:  
Address:  
City:       State:
Relationship:       Phone/EXT.
Named In Will?:    YES     NO     UNK
Pets:     YES   NO  
    Type:      Held By:  
     

CONTACTS WITH MORE INFORMATION OR INTEREST IN DECEDENT OR ESTATE
First Name:  
Last Name:  
Phone:      Relationship:  
     
First Name:  
LastName:  
Phone:      Relationship:  
     
ESTATE COMPOSITION:
CASH:   $    Held By:
Facility Trust Funds:   $    Contact:
Phone:  
   
Bank Accounts:    
Name of Bank:  
Branch Address:      Phone:
Account Number:  
Balance $      Date: (Format ## / ## / ####)
     
Name of Bank:  
Branch Address:      Phone:
Account Number:  
   Balance $      Date: (Format ## / ## / ####)
Bank Accounts:     Any Names(s) on Account with Decedent; If Checked, List Here:
     
STOCKS, BONDS, SECURITIES:    YES     NO     UNK.
Description:  
Certificates Held At:  
     
MOTOR VEHICLES    YES     NO     UNK.
Make & Model:       Year:
License Number:       Location:     Key Held By:
     
Make & Model:       Year:
License Number:       Location:     Key Held By:
LIFE INSURANCE:  YES     NO     UNK.
Company:       Face Amount:   $
Policy Number:      Beneficiary:  
     
     

 
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