Report on Deceased Person by kellena87

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Report on Deceased Person
                                                                                       Oregon Department
                                                                                       of Human Services
 Client                                                                         1
Last Name                             First Name                     Initial(s)        SENIORS AND
Date of death                         Date of birth                                    PEOPLE WITH
Location/facility where decedent died                                                  DISABILITIES
Residence prior to death:                   Initial application date
Street
City                                       State              Zipcode
Funeral paid by H Family             $              H T&A funds $
                  H Burial insurance $              H Other         $
                  H Bank account $
 Spouse                                                                         2
Status H Married H Divorced H Deceased / Date of Death: / /                         SDS 454D
Date of birth                         Case number                                   Client
Social Security number
Last name
First name                            Initial(s)                                    Date sent
Previous names used
Street                                                                              Case number
City                                  State            Zipcode
 Will                                                                           3   Prime number
Did decedent leave a will                                      H yes H no
Attorney/location of will                                                           Date of birth
Street                                        City
State              Zipcode                    Telephone                             Social Security #
Real property                                                                   4
Street                                        City                                  Program
State              Zipcode                    Telephone
Title holder                       Date acquired                                    Branch code
Occupied by spouse H yes H no H other (specify)
Market value                                         $                              Worker
Taxes        H CurrentH Delinquent H Deferred Amount $
Sold real property                                   $      5
H Contract   H Mortgage   H Trust deed H Cash H Life estate                         Phone#
Purchaser
Street                                        City
State             Zipcode                     Telephone                                    Page 1 of 2
Sale price $          Balance due $             Monthly payments $
                                                                                          SDS 0454D (11/07)
 Personal property                                                                               6
Item                             Amount     Location/Description
Bank Account#(s)                 $
                                 $
Cash                             $
Securities                       $
T&A account                      $
Excess credits (in nursing home) $
P.I. funds                       $
Other                            $
Mobile Home / Trailer Make , Model & Year:
Registered Owner:                                             Value: $
Mobile Home / Trailer, Make , Model & Year:
Registered Owner:                                            Value: $
Automobile, Make , Model & Year:
Registered Owner:                                            Value: $
Automobile, Make , Model & Year:
Registered Owner:                                            Value: $
 Heirs                                                                                           7
Name                                                  Relationship
Street                                City                    State      Zipcode
Telephone Number
Name                                                  Relationship
Street                                City                    State      Zipcode
Telephone Number
 Remarks                                                                                         8




Signature ( Worker)                                                          Date


Estates Administration Phone Number 1-800-826-5675 or 503-378-2884                 Page 2 of 2
                                                                                    SDS 0454D (11/07)

								
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