For Deceased Veteran

AGENT ORANGE QUESTIONNAIRE II IS ON BEHALF OF A DECEASED VETERAN

Thank you for your inquiry. Please complete the questionnaire that follows the text of this message regarding your possible participation in an "Agent Orange" lawsuit. If you return the questionnaire to us electronically, we will review your information and update you as soon as possible as to the litigation. If you can’t submit it by email, you may also print the form out and submit it by mail – however it may take longer to respond to you. Thank you again very much for your time and interest

Sincerely,

Gerson H. Smoger

3175 Monterey Blvd., Ste. 300

Oakland, CA 94602

AGENT ORANGE QUESTIONNAIRE II FOR DECEASED VETERAN (please just submit the answers)

Please fill in your e-mail address.

Name

Your Name

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Home Phone

Work Phone

Cell Phone

Fax

Deceased Veteran's Name

Last Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Veteran's Date of Birth

Veteran's Social Security #

Date of Death

Cause of Death

Dates of Viet Nam Service

Branch of Service and Rank

Briefly describe the location of Viet Nam service, the duties, and the location of exposure to herbicides, including Agent Orange, of the deceased veteran:

What Agent Orange related conditions did the deceased veteran die from (If cancer, please describe the cell type and location):

When was the decedent diagnosed with the above condition(s):

Please list any family members related by blood who have suffered or are suffering from the medical conditions described above?

Did the decedent smoke? How many packs per day for what period of time?

Was the veteran receiving or seeking VA or SS disability? When did the decedent first apply?

Did the decedent have a claim for Veteran’s benefits related to his Agent Orange Exposure? Was the claim approved or rejected? When was it approved or rejected?

Was the decedent aware of, or did the decedent participate in the original Agent Orange lawsuit or settlement? Please describe?

Was the decedent rated as 100% disabled by the VA? If so, when was the decedent first 100% disabled and for what periods of time?

Please feel free to add any additional comments you would like to make, or ask any questions you might have and we will get back to you.

Please fill in your EMAIL address

AGENT ORANGE QUESTIONNAIRE II (if you need to send it in by mail)

INFORMATION OF PERSON FILLING OUT THIS FORM:

YOUR Name:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

Fax:

Email:

Please identify two individuals (relatives or friends) who will always know where to contact you.

Name:

Address:

Phone #:

Email:

DECEASED VETERAN’S INFORMATION BELOW:

Deceased Veteran’s Name:

Last Address:

City:

State:

Zip:

Deceased Veteran’s Date of Birth:

Place of Birth:

Social Security # (optional)

Date of Death:

Cause of Death

(PLEASE be as specific and as detailed as possible; please provide the cell type of any cancers)

Dates of Viet Nam Service:

Branch of Service and Rank:

Briefly describe the location of Viet Nam service, the duties, and the location of exposure to herbicides, including Agent Orange, of the deceased veteran:

What Agent Orange related conditions did he suffer from (If cancer, please describe the cell type and location):

When was the decedent diagnosed with the above condition(s):

Please list any family members related by blood who have suffered or are suffering from the medical conditions described above?

Did the decedent smoke? How many packs per day for what period of time?

Was the veteran receiving or seeking VA or SS disability? When did the decedent first apply?

Did the decedent have a claim for Veteran’s benefits related to his Agent Orange Exposure? Was the claim approved or rejected? When was it approved or rejected?

Was the decedent aware of, or did he participate in the original Agent Orange lawsuit or settlement? Please describe?

Was the decedent rated as 100% disabled by the VA?

If so, when was the decedent first 100% disabled and for what periods of time?

Please feel free to add any additional comments you would like to make, or ask any questions you might have and we will get back to you.

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Your Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Home Phone
Work Phone
Cell Phone
Fax
Deceased Veteran's Name
Last Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Veteran's Date of Birth
Veteran's Social Security #
Date of Death
Cause of Death
Dates of Viet Nam Service
Branch of Service and Rank
Briefly describe the location of Viet Nam service, the duties, and the location of exposure to herbicides, including Agent Orange, of the deceased veteran:
What Agent Orange related conditions did the deceased veteran die from (If cancer, please describe the cell type and location):
When was the decedent diagnosed with the above condition(s):
Please list any family members related by blood who have suffered or are suffering from the medical conditions described above?
Did the decedent smoke? How many packs per day for what period of time?
Was the veteran receiving or seeking VA or SS disability? When did the decedent first apply?
Did the decedent have a claim for Veteran’s benefits related to his Agent Orange Exposure? Was the claim approved or rejected? When was it approved or rejected?
Was the decedent aware of, or did the decedent participate in the original Agent Orange lawsuit or settlement? Please describe?
Was the decedent rated as 100% disabled by the VA? If so, when was the decedent first 100% disabled and for what periods of time?
Please feel free to add any additional comments you would like to make, or ask any questions you might have and we will get back to you.
Please fill in your EMAIL address