Form PE58A
STATE OF VERMONT
Docket No._____________________
VERIFIED PETITION FOR
ISSUANCE OF CERTIFICATE OF PRESUMED DEATH
1. Was a resident of this probate unit;
2. Has been absent for a continuous period of five years;
3. Has not been heard from or, after diligent search, been seen, during this period; and
4. There is no satisfactory explanation for this person’s absence.
5. This person was last seen alive on
Spouse, child, other near relative
To the best of my knowledge, and belief, the following statements are true about this person:
Birthplace (Town and State)
Mother/Parent’s Birth Name
Father/Parent’s Birth Name
Spouse/Civil Union Partner
Ever in U.S. Armed Forces
Therefore, I request the Court to direct the Chief Medical Examiner to complete and sign a certificate of
presumed death of this person.
Attached are:
(1) Entry fee of payable to “Vermont Superior Court” [see instructions]
(2) One or more affidavits of diligent search for the person.
(3) List of Interested Persons
[Probate Form 2]
PETITIONER SIGNATURE: