Petition To Settle Wrongful Death And Survival Actions

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5-19-16
FIRST JUDICIAL DISTRICT OF PENNSYLVANIA
COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY
1
Trial Division - Civil
:
TERM, 20
:
:
:
:
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.

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