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Gallery

523 Jamie Ct

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Address

910 2nd Street, Suite A
Sacramento, Ca 95814
contact@webhouserealty.com

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Decedent's Information

Full Name of Informant *

First

Last

Street Address of Informant

Address Line 1

Address Line 2

City

State

Zip Code

Email Address

Full Name of Decedent *

First

Last

Street Address of Decedent

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth of Decedent//

Date of Death of Decedent//

Cause of Death

Marital Status of Decedent

Social Security Number of Decedent

Was Decedent Ever On Medicaid ?

YES
NO

Was Decedent Ever On Medicare ?

YES
NO

Was Decedent on SSI at Death ?

YES
NO

Was Decedent Ever on SDI at Death ?

YES
NO

Ethnicity

Personal Representative

Decedent Name *

First

Last

Named in Will ?

YES
NO

Name *

First

Last

Street Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth//

Email Address

Social Security Number

Phone Number

Relationship to the Decedent

Upload Picture of Drivers License

Click or drag a file to this area to upload.

Upload Additional File

Name *

First

Last

Decedent Name *

First

Last

Street Address

Address Line 1

Address Line 2

City

State

Zip Code

Upload File

Click or drag files to this area to upload. You can upload up to 5 files.

DECEDENT'S CHILDREN

Decedent's Name *

Name *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Date of Birth

Month

Day

Year

Social Security Number

Email Address

Phone Number

Upload Picture of Drivers License

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Signature