Free pc549.p65 - Michigan

Approved, SCAO

JIS CODE: PED

STATE OF MICHIGAN PROBATE COURT COUNTY OF

PETITION TO ESTABLISH DEATH OF ACCIDENT OR DISASTER VICTIM

FILE NO.

In the matter of 1. I am interested in this matter as 2. Presumed decedent information: Domicile:
City/Township/Village Date of birth

, presumed decedent . XXX-XXLast four digits of SSN Name of foreign country if citizen of foreign country County State

3. This petition is being filed not less than 63 days nor more than 7 years after the accident/disaster. 4. The presumed decedent apparently died as result of an accident or a disaster which occurred on or about
Date

and
Location

Time

, if known, , within this county.

a. at

b. upon or within the Great Lakes or their connecting waters, at a location adjacent to this county. c. at a location outside of Michigan or its adjoining waters but the presumed decedent was domiciled in this county at the time of death. 5. The facts and circumstances concerning the accident or disaster are as follows:

6. The reasons I believe the presumed decedent died in the accident or disaster are as follows:

(PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only

PC 549 (9/05)

PETITION TO ESTABLISH DEATH OF ACCIDENT OR DISASTER VICTIM

MCL 700.1207(e), (f), MCL 700.1208

7. The body of the presumed decedent

is unidentifiable. has disappeared.

8. The name, age, and relationship to the presumed decedent and the address of each person known or believed to be an heir of the presumed decedent are as follows: NAME AGE RELATIONSHIP RESIDENCE

9. Of the above heirs, the following are under legal disability: NAME DISABILITY
(name, address, capacity)

REPRESENTED BY:

I REQUEST that the court establish the location of the accident or disaster, the cause, and date of the presumed decedent's death, and, if possible, the time of death. I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief.

Date

Petitioner signature

Attorney signature Attorney name (type or print) Address City, state, zip Telephone no. Bar no. Petitioner name (type or print) Address City, state, zip Telephone no.