Please complete the form below, and click Submit Form button.
| Your Name | |
| Your Address | |
| Your City, State, Zip Code | |
| Your Email* | |
| Your Home Phone | |
| Your Cell Phone (optional) | |
| Your Work Phone | |
| Name of Deceased | |
| Town or City, of Deceased | |
| Your Relationship to Deceased | |
| Age of Deceased | |
| Date and Time of Death | |
| Location of Death |
If the death was caused by an accident, please complete the following:
Date and Time of Accident
Description of Accident:
(Please include a description of what caused the deceased's accident, and who
was at fault.)
Describe Deceased's Injuries:
For motor vehicle accidents, describe the damage to the vehicles:
If the death was caused by medical malpractice, please complete the following:
Doctor who committed medical malpractice
Hospital where medical malpractice was committed
Has another doctor advised you that medical malpractice was committed? Yes No
Please describe the medical condition for which the deceased was treated, and the type of treatment he or she received:
Please explain why you believe that the medical treatment the deceased received was improper (summary of the medical malpractice):
Please click Submit button and wait for the Form Confirmation page. If the Form Confirmation page does not appear, an error has occurred in the submission of this form. Therefore, kindly contact us by email, or call us at (212) 571-6848 or toll free at (877) I WAS HURT.
Thank you for your submission.
You can reach Michael W. Goldstein at (212) 571-6848, or click NY personal injury lawyer to send an e-mail.
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