5-19-16
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA
COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY
1
Trial Division - Civil
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TERM, 20
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NO.
PETITION TO SETTLE WRONGFUL
DEATH AND SURVIVAL ACTIONS
To The Honorable, the Judges of the Said Court:
The Petition of ________________________, Administrator/Executor of the Estate of
__________________, Deceased, by his/her attorney, ______________________, Esquire,
respectfully requests:
1.
Petitioner is ____________________ who was appointed Administrator/Executor of the
Estate of _____________________, Deceased, on__________________, ____, by the Register of
Wills of _________________ County. A copy of the Decree of the Register is attached.
2.
The plaintiff decedent died on ____________________ as a result of
(set forth relevant
information describing the underlying negligence or cause of action as required by Phila. Civ. R. 2206(D)):
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
(If additional space is needed, please continue on separate sheet).
3.
Notice of the institution of the action as required by Pa. R.C.P. 2205 and Philadelphia Civ. R.
2206 (E) was given on _______________________ to the following individuals:
NAME
ADDRESS:
______________________________
_____________________________
______________________________
_____________________________
______________________________
_____________________________
Pursuant to Phila. Civ. R. 2206 (E) Petitioner has served a copy of this Petition on the
4.
1
In the event the Petition is filed in the Orphans’ Court Division, the caption must comply with Pa.O.C. 3.2.