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2. Requestor Information
4. First Name*
5. Last Name*
7. Requestor Relationship To Victim*
   -- Select One --ChildGrandparentGrandparent-in-lawParentParent-in-lawSiblingSpouseStepchildExercised in loco parentis control over a victim under the age of 18 yearsDesignated attroney in good standing with the State Bar of Gerogia (retained by one of the above classifications of persons)Other
9. Email*
10. Phone Number*
12. Street Address*
13. Apt/Suite/Other
15. City*
16. State*
17. Zipcode
19. Victim Information
21. First Name*
22. Last Name*
23. Date Of Birth
25. Date Of Death (Approximate)*
26. Place Of Death*
28. What agency initially investigated this death?
29. GCPD Case Number
31. If a Coleman-Baker Act application has been submitted, other than to the Gwinnett Police Department, when was it submitted and to what agency?
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33. 1. Receive an email copy of this form.
34. Email address

    This field is not part of the form submission.

35. Submit

* indicates a required field