Page 1 of 3 CIV-715 (2/18)(cs) AFFIDAVIT IN SUPPORT OF PETITION RE UNCLAIMED BODY AS 12.65.100 & 110 IN THE DISTRICT/SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of: ) ) ) ) CASE NO. ) Deceased ) AFFIDAVIT IN SUPPORT OF ) PETITION FOR ORDER AUTHORIZING DISPOSITION OF UNCLAIMED BODY (UNDER AS 12.65.100) I, the undersigned, swear or affirm under penalty of perjury that the following is true to the best of my knowledge and belief following diligent inquiry: 1. I became aware of, and am providing, the following information in my capacity as: (funeral home employee, law enforcement investigator, landlord, guardian, health facility employee, etc.) 2. The deceased person named above died at or near , Alaska, on or about , under the following circumstances: 3. Other information known about deceased: Last known address Last employer Other 4. No person has appeared to claim the body for burial. a. The following relatives or interested persons were located, but are unwilling or unable to claim the body: Name Relationship Address/Phone b. The following relatives or interested persons were identified but cannot be located: Name Describe Attempts to Locate American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 3 CIV-715 (2/18)(cs) AFFIDAVIT IN SUPPORT OF PETITION RE UNCLAIMED BODY AS 12.65.100 & 110 c. The following efforts yielded no names of relatives or interested persons: contacted acquaintances, neighbors, etc. Person Contacted Relationship to Deceased Address/Phone searched the following records (such as vital records, employment, PFD records, military records, court records): examined the personal effects and other property of the decedent located at: for the purpose of locating information about relatives. Other: 5. I have no information regarding whether the deceased left information or instructions regarding funeral or disposition. The deceased left information or instructions regarding funeral or disposition wishes as follows (when were instructions left, what were the instructions): 6. No provision has been made for the body under AS 13.50 (the Uniform Anatomical Gift Act). I made the following efforts to confirm this: and and found no organ donor card. determined that no such gift is made in it. Other efforts to determine whether a gift has been made: American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 3 CIV-715 (2/18)(cs) AFFIDAVIT IN SUPPORT OF PETITION RE UNCLAIMED BODY AS 12.65.100 & 110 7. Property. I am not aware of any money or other property belonging to the deceased. I am aware of the following money or property of the deceased: personal effects located at other property located at 8. Other information relevant to the petition: Date Signature of Person Making this Affidavit Type or Print Name and Title State Office/ Dept./Funeral Home/Other Ofc. Address Telephone Number Fax Number Subscribed and sworn to or affirmed before me at , Alaska, on . (date) (SEAL) Clerk of Court, Notary Public, or other person authorized to administer oaths. My commission expires American LegalNet, Inc. www.FormsWorkFlow.com