GAY, JACKSON & MCNALLY, L.L.P.
ATTORNEYS AT LAW
P.O. BOX 10
500 NORTH ARENDELL AVENUE
ZEBULON, NORTH CAROLINA 27597
ANDY W. GAY
DARREN G. JACKSON
PAT MCNALLY
PHONE: (919) 269-2234
FACSIMILE: (919) 269-2052
E-MAIL: darren_jackson@bellsouth.net
WRONGFUL DEATH INTAKE SHEET
For
_________________________________________ (decedent)
I.
BACKGROUND
Name_______________________________________________________________________
Address_____________________________________________________________________
Family relationship to decedent___________________________________________________
Other family members__________________________________________________________
Spouse______________________________________________________________________
Parents______________________________________________________________________
Children_____________________________________________________________________
Sex___________________________________________________________________
Age___________________________________________________________________
Where residing__________________________________________________________
Date of marriage (if spouse)______________________________________________________
Educational Background_________________________________________________________
Employment/student background__________________________________________________
II.
DEATH OF DECEDENT
Date of Death_________________________________________________________________
How learned of death___________________________________________________________
From whom___________________________________________________________________
Where_______________________________________________________________________
When_______________________________________________________________________
Who with at time_______________________________________________________________
What told to you about accident___________________________________________________
Death Certificate_______________________________________________________________
Autopsy______________________________________________________________________
Death Summary_______________________________________________________________
III.
DECEASED
Where born and raised__________________________________________________________
Age at death__________________________________________________________________
Education____________________________________________________________________
Positions held_________________________________________________________________
General health before accident___________________________________________________
Hobbies and activities___________________________________________________________
Social activities________________________________________________________________
Volunteer work________________________________________________________________
Plans for the future_____________________________________________________________
Family activities_______________________________________________________________
Special or distinctive traits of deceased_____________________________________________
Special aspects of relationship between deceased and beneficiary_______________________
____________________________________________________________________________
IV.
INJURIES TO DECEASED
Nature and extent of injuries______________________________________________________
Evidence of conscious pain and suffering (and who witnessed)__________________________
____________________________________________________________________________
Where and when expired________________________________________________________
Efforts to resuscitate____________________________________________________________
Whether beneficiary witnessed accident and/or efforts to resuscitate at scene of accident______
____________________________________________________________________________
V.
LOSS OF INCOME OF DECEASED
Employment of deceased________________________________________________________
Position or title________________________________________________________________
Degrees or licenses held________________________________________________________
Length of employment__________________________________________________________
Earnings_____________________________________________________________________
Fringe benefits with employer_____________________________________________________
Work history__________________________________________________________________
Opportunities for future before accident (plans)_______________________________________
Education history______________________________________________________________
Special skills and training________________________________________________________
VI.
LOSSES TO SPOUSE BENEFICAIRY
Loss of sonsortium_____________________________________________________________
Affection_______________________________________________________________
Solace_________________________________________________________________
Comfort________________________________________________________________
Companionship__________________________________________________________
Society________________________________________________________________
Assuistance____________________________________________________________
Sexual Relations_________________________________________________________
Emotional Support_______________________________________________________
Love__________________________________________________________________
Loss of household services______________________________________________________
House Repairs__________________________________________________________
Auto Repairs____________________________________________________________
Yard Work______________________________________________________________
Running errands_________________________________________________________
Cooking________________________________________________________________
Cost of household services______________________________________________________
Replacement cost________________________________________________________
Going rate for such services________________________________________________
Number of hours per week or month services performed on average______________________
VII.
LOSSES TO CHILD BENEFICIARY
Role model___________________________________________________________________
Counsel and advice____________________________________________________________
Tutoring_____________________________________________________________________
Encouragement_______________________________________________________________
Companionship________________________________________________________________
Financial assistance____________________________________________________________
VIII.
LOSSES TO PARENT BENEFICIARY
Companionship and society______________________________________________________
Assistance with chores__________________________________________________________
Advice and counsel, from adult child_______________________________________________
VIV.
MENTAL ANGUISH AND EMOTIONAL TRAUMA
Period immediately after death____________________________________________________
Funeral______________________________________________________________________
Grieving period_______________________________________________________________
Long term effects______________________________________________________________
Physical manifestations_________________________________________________________
Sleeplessness___________________________________________________________
Loss of appetite_________________________________________________________
Worry about the future__________________________________________________________
Living alone_____________________________________________________________
No spouse______________________________________________________________
No parent______________________________________________________________
Economic impact________________________________________________________
X.
EFFECT ON FAMILY
Less expensive house or apartment________________________________________________
Less expensive vehicle__________________________________________________________
Spouse/children have started working______________________________________________
Spouse had to quit work_________________________________________________________
Children have dropped out of school_______________________________________________
Bill collectors and collection letters_________________________________________________
Dropped or lowered insurance____________________________________________________
Wearing old clothes____________________________________________________________
Inadequate food_______________________________________________________________
Drawing welfare/food stamps/ persistent financial problems_____________________________
XI.
BYSTANDER RECOVERY BY BENEFICIARY
Physical location at time of accident________________________________________________
Of deceased__________________________________________________________________
Of beneficiary_________________________________________________________________
Beneficiary viewed accident______________________________________________________
Beneficiary heard accident ______________________________________________________
Beneficiary saw rescue efforts____________________________________________________
Beneficiary saw attempts to resuscitate_____________________________________________
Experience perception of accident or injury in some other way___________________________
Effect of witnessing injury or death of loved one______________________________________
Fright__________________________________________________________________
Mental anguish__________________________________________________________
Emotional reaction
(trauma)_________________________________________________
Beneficiary of normal emotional makeup____________________________________________
Psychiatric/psychological evaluation_______________________________________________
XII.
NURSING SERVICES TO DECEDENT BEFORE DEATH
Provided to spouse or adult child beneficiary_________________________________________
Types of services provided_______________________________________________________
Being available for assistance______________________________________________
Feeding________________________________________________________________
Dressing_______________________________________________________________
Change bed____________________________________________________________
Toilet assistance_________________________________________________________
Inspecting for skin care____________________________________________________
Monitor and check temperature, consciousness, needs, wakefulness________________
______________________________________________________________________
Personal hygiene________________________________________________________
Value of nursing care in community-vocational nurse__________________________________
LPN___________________________________________________________________
Sitters_________________________________________________________________
RN____________________________________________________________________
Number of hours spent__________________________________________________________
Why services needed___________________________________________________________
XIII.
SPECIAL DAMAGES
Medical expenses______________________________________________________________
Doctors________________________________________________________________
Hospitals_______________________________________________________________
Ambulance_____________________________________________________________
Medications_____________________________________________________________
Nursing services before death____________________________________________________
Funeral expenses______________________________________________________________
Burial expenses_______________________________________________________________
THINGS TO REQUEST FROM CLIENT/FAMILY
___
Decedent’s federal and state tax returns (up to five years)
___
Birth Certificate
___
Children of decedent’s birth certificates
___
Death Certificate
___
Autopsy report (if available)
___
Military discharge papers if applicable
___
Photographs of decedent in your possession:
With his family and friends, pertaining to the accident, personal history,
accomplishments, of the funeral, headstone, etc., and any other photos that would
help convey a feeling of who the decedent was as a person and show his
interaction with his family, friends, relatives, coworkers, etc. Also, please provide
a recent family portrait if available.
___
All video of decedent in your possession:
With his family and friends, pertaining to the accident, personal history,
accomplishments, of the funeral, headstone, etc., and any other videos that would
help convey a feeling of who the decedent was as a person and show his
interaction with his family, friends, relatives, coworkers, etc.
___
Marriage certificate
___
Last will and testament
___
Any and all bills and statements pertaining to the funeral or burial expenses
___
Employment contract
___
Last paycheck
___
Any awards, plaques, certificates, citations received by the decedent
___
All sympathy cards and letters received
___
Any and all letter, correspondence or paper writing written by decedent
___
Any and all obituary notices
___
Any evidence showing decedent shared income with beneficiary
___
A sample of items that decedent may have made (crafts, hobbies, etc)
___
Letters testamentary or letter of administration of the person appointed
___
Pictures of accident including scene and vehicles involved
___
Repair records
___
A narrative written by each family member that is able, describing in detail the
loss he or she has experience.