COURT MEMORANDUM
DECEASED ESTATE
Date: ______
1.NAME OF DECEASED: ______
2.DECEDENT’S LAST ADDRESS: ______
3.DATE OF BIRTH: ______DATE OF DEATH: ______
4.SOCIAL SECURITY # ______MARRIAGE DATE: ______
5.INFORMANT: ______PHONE #: ______
ADDRESS: ______
6.PLACE OF DEATH: Institution: ______Town: ______
7.DID THE DECEDENT LEAVE A LAST WILL AND TESTAMENT:YES NO
(if not filed, name and address of person who has it) ______
8.DID THE DECEDENT LEAVE A SPOUSE?YesNo Never married Widowed Divorced
NAME OF SPOUSE: ______
9.LIST NAMES AND ADDRESSES OF CLOSEST RELATIVES:
A.CHILDREN(include dates of birth for minors). Are all the children also children of the surviving spouse? Yes No
______
______
______
______
B.DECEASED CHILDREN - did the decedent have any children which did not survive him or her? YES NO
If yes, did the predeceased child leave any children?YES NO If yes, please name them:
______
______
______
______
C.If no surviving children or grandchildren, list PARENTS:
______
______
D.If no surviving children, grandchildren or parents, list BROTHERS AND SISTERS
and representatives of deceased brother’s and sisters:
______
______
______
______
E.If no surviving children, grandchildren, parents, brothers or sisters, list UNCLES AND AUNTS:
______
______
F.If no surviving children, grandchildren, parents, brothers, sisters, uncles or aunts, list COUSINS:
(first degree, second degree, etc.)
______
______
10.ARE ANY OF THE HEIRS-AT-LAW IN THE MILITARY OF THISNATION OR ANY OF ITS ALLIES?
(If so, give name, address and branch of military): ______
11.HAVE YOU RETAINED AN ATTORNEY? Please give name and address: ______
______
12.ASSETS IN THE DECEDENT’S OWN NAME ALONE (please include approx. value of assets):
Real property: ______
Bank Accounts: ______
______
______
Stocks, Brokerage Accounts and Savings Bonds: ______
______
Automobiles (please include VIN): ______
13.ASSETS IN JOINT OR SURVIVORSHIP OWNERSHIP WITH THE DECEASED (please include approx. value of assets)
A.Real Estate:Yes No Where: ______
Mortgage:Yes No Where: ______Amount left: ______
B.Bank Accounts: ______
______
______
______
______
C.Stocks and Brokerage Accounts: ______
______
D.Savings Bonds: ______
______
E.Automobiles (please include the VIN): ______
______
F.Other Assets not listed above: ______
______
14.LIFE INSURANCE (please name any beneficiaries): ______
______
15.RETIREMENT - ANNUITIES - PROFIT SHARING PLAN (State the portion the deceased contributed to it)
______
______
16.ANTE MORTEM TRANSFERS: ______
17.WAS THE DECEDENT EVER A PATIENT IN A STATE-OPERATED VETERAN’S HOSPITAL?Yes No Where: ______
18.DID THE DECEDENT EVER RECEIVE ANY INSTITUTIONAL CARE FROM THEST of CT?Yes No
19.WAS THE DECEDENT RECEIVING ANY VETERAN’S BENEFITS?Yes No
20.WAS THE DECEDENT,OR ANY BENEFICIARY,RECEIVING ANY STATE WELFARE BENEFITS?Yes No
21.WAS THE DECEDENT RECEIVING ANY STATE TITLE 19 MEDICAL BENEFTIS?Yes No
22.DID THE DECEDENT HAVE A CONSERVATOR APPOINTED?Yes No
NAME AND ADDRESS OF CONSERVATOR: ______
23.DID THE DECEDENT HAVE A SAFE DEPOSIT BOX IN HIS OR HER OWN NAME?Yes No
If so, where? ______
24.WAS THE DECEDENT ACTIVE IN THE MILITARY SERVICE AT THE TIME OF DEATH?Yes No
25.NAME OF FUNERAL HOME: ______
Has funeral bill been paid?Yes No If yes, who paid the bill? ______