Fill and Sign the Death Civil Form

IN THE ______________ COURT OF ______________ COUNTY STATE OF ________________       ) )       ) Petitioner/Plaintiff, ) ) ) NO.       Vs. ) )       ) Respondent/Defendant ) ) COMPLAINT _______________, individually and as Administrator of the Estate of _______________, files this Complaint against _______________ and in support would show the following: I. PARTIES. 1. _______________, an adult resident of the State of __________, is the only child of _______________, deceased. _______________ is the duly appointed administrator of the Estate _______________, which has been opened in _________ County, _________. 2. _______________ is a corporation organized and existing under the laws of the State of __________, with its principal place of business in __________ County, __________. _______________ sold _______________ a mobile home on or about the _____ day of____________, 20____. _______________ later delivered and installed that mobile home for _______________. The above transaction and installation occurred within __________ County, __________. 3. _______________'s agent for service of process is _______________, who may be served at ____________________________. - 1 - PLAINTIFF’S COMPLAINT This Court has jurisdiction over this cause and venue is proper. II. FACTS. 4. _______________ sold _______________ a mobile home on or about the ______ day of____________, 20____. As part of that transaction, _______________ also delivered and installed the mobile home. 5. Installation of the mobile home included, among other things, constructing and setting up stairs leading to the front and back doors of the mobile hone. 6. _______________ installed the front stairs on _______________’s mobile home so that one would walk up the stairs beside and parallel to the hone rather than perpendicular to and facing the home. Installation of the stairs in this way left a large "gap" at the top of the stairs which one had to jump over in order to enter the mobile home. A photograph accurately depicting the way in which _______________ installed the stairs is attached hereto as Exhibit 1. 7. As a result of the improper construction and installation of the stairs, _______________ fell from the stairs and sustained severe injuries. III. CLAIM ONE - NEGLIGENCE. 8. _______________ had a duty to exercise due care in installing the stairs to the mobile home of _______________. _______________ breached that duty in the manner in which they installed the stairs and as a proximate result, _______________ sustained severe injuries. IV. CLAIM TWO - WRONGFUL DEATH 9. Pursuant to ________ Code, _______________ is a statutory beneficiary and entitled to bring this claim against _______________ for the wrongful death of - 2 - _______________. As a direct and proximate result of the aforementioned negligent, wanton, and reckless conduct of _______________, _______________ sustained severe injuries, which proximately resulted in his death. Thus, pursuant to __________ Code, a cause of action for wrongful death exists and _______________, as the only child of _______________, is entitled to damages. V. CLAIM THREE - PUNITIVE DAMAGES. 10. The manner in which _______________ constructed and installed the stairs to the mobile home of _______________ evidenced a willful, wanton and/or reckless disregard for the rights of _______________ and entitles the Plaintiffs to receive punitive damages in an amount sufficient to punish _______________ for such conduct and deter it from committing similar acts in the future. VI. RELIEF. 11. _______________ demands the following relief from _______________: (a) Actual damages including, without limitation, medical expenses, pain and suffering, and all other damages sustained by the deceased; (b) Punitive damages in an amount sufficient to punish _______________ and deter similar conduct in the future; (c) Any and all other damages, costs or other charges which the Court deems appropriate. Respectfully submitted, Dated: Name:       Title:       Address:       Address:       City, State, Zip:       Phone:       - 3 - Fax:       E-Mail:       Attorney No.:       CERTIFICATE OF SERVICE I, ______________________________, do hereby certify that I have this day mailed, U.S. Mail, postage prepaid, a true and correct copy of the above and foregoing to __________________________________, at the following address; ___________________________________________________________________ THIS the ____ day of _____________, 20____. _________________________________ - 4 -