WRONGFUL DEATH INQUIRY FORM*

You may Email by clicking on the submit button below or print this form to mail or fax to us:

Burkhalter, Rayson & Associates, P.C.

P.O. Box 2777

Knoxville, TN 37901-2777

Fax No.: (865) 524-0172

To request more information, please complete the form below.
*Bold fields are required*

*Email:*

*Your Name:*

*Date:*

*Name of deceased:*

*Your relationship to the deceased:*

*Any surviving spouse and/or children? If so, who?*

*Age of deceased:*

*Date of incident:*

*Location of incident:*

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

*Describe what happened which resulted in the death:*

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

Was there an autopsy?

If so, do you have the results?

Was there any estate?

No If so, has the estate been probated?

If so, where and who the administrator/administratrix?

Other pertinent information:

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

*Your home phone number:*

Work phone number

Other phone number:

*Your address ( street, city, st and zip ):*

*When and how did you hear about us?*

Your information is being sent directly to Burkhalter, Rayson & Associates, P.C., and by law, all communications to us are 100% confidential.