SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ INT _________ _________ IDD _________ In re: _______________________________________ An Adult NOTICE OF DEATH The Clerk of this Court will please be advised that _________________________ __________________________________ died on _____________________________, 20______. ____________________________________ Signature ____________________________________ Typed name ____________________________________ Address (actual address/not Post Office Box) ____________________________________ ____________________________________ ____________________________________ Telephone number ____________________________________ Email address ____________________________________ Bar number (if filer is an attorney) January 2014 � 951.10.v3 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE I certify that on the ____ day of ____________________, 20____, a copy of this filing was either eServed in accordance with the provisions of Administrative Order 13-15 or served by first class mail, postage prepaid, on the following persons (list names and complete mailing addresses): __________________________ Signature August 2012 � 951.10.v1 American LegalNet, Inc. www.FormsWorkFlow.com