RELEASE
CLAIMS
BASED ON SPOUSE'S DEATH
I,
______________________________________________________ (Name), residing at
___________________________________________________________ (Address),
1for
myself, my heirs, legal representatives and assigns, for the sole consideration
of ________________ Dollars, receipt of which is hereby acknowledged, release
and forever discharge ______________________________________________
(Releasee), of: __________________________________________________________
(Address), __________ (his or her) heirs, legal representatives,
_____________________ (Agents and employees,) from any and all claims, demands
and causes of action, whether past, present or future, arising out of or as a
result of the fatal injury of _________________ _______________________________
(Deceased spouse), my ________________ (Husband or wife), that occurred on
___________________________ (Date), at or near
_________________________________________________ (Specify location), under the
following circumstances: _____________________________________________
____________________________________________________________________________________________________________________________
(Explain).
Without
limiting the generality of the above, this release includes all claims for
personal injury, property damage, alleged wrongful death of
_____________________
____________________________
(Deceased spouse), loss of services and expenses as a result of such
occurrence.
I
agree to indemnify ____________________________________________ (Releasee),
_______ (His or her) heirs, legal representatives,
______________________________ (Agents and employees,) against any and all
further claims, demands, rights, liabilities and suits that may hereafter be
made or brought at any time by me, for myself, or in behalf of the minor
children of ____________________________________ (Deceased
spouse),
or by any other party arising out of or as a result of the above-described
occurrence.
The
sum specified in this release is the sole consideration for this release and
such consideration is contractual and not a mere recital. All agreements and understandings between
the parties are reflected herein. I understand that _______________________
(Releasee) does not admit liability, but expressly denies the same, and that
the consideration is paid in compromise of a doubtful and disputed claim or
claims and to avoid the trouble and expense of further investigation and
litigation. I have executed this
instrument solely in reliance on my own judgment and not in reliance on any
representations or promises of _______________ (Releasee) or __________ (His or
her) attorneys or representatives. I
have read and fully understand this instrument.
In
witness whereof, I have executed this release at ____________________________
(Designate place of execution) on ____________________________________ (Date).
_____________________________________ ____________________
Signature Date
______________________________________ ______________________
Witness Date
______________________________________ ______________________
Witness Date
______________________________________ ______________________
Witness Date
