Rev. 6/2017 KSJC 1 [CAPTION] STATEMENT NOTING A PARTY222S DEATH In accordance with K.S.A. 60-225(a)(2), (name the person) , who is (a party to this action) (a representative of or successor to the deceased party) notes the death during the pendency of this action of name (describe as party in this action) . CERTIFICATE OF SERVICE I certify that a copy of the above Statement Noting a Party222s Death claim was served on (Name) on the day of , 20 , as follows: . (Signature of attorney) (Name), Attorney for Bar Registration Number Address Telephone [Facsimile number] [Email address] Authority K.S.A. 60-225(a)(1). American LegalNet, Inc. www.FormsWorkFlow.com