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Get DoL EE-2 2005

Programs OMB Number: Expiration Date: Note: Provide all information requested below. Do not write in the shaded areas. 1215-0197 08/31/2010 Deceased Employee Information (Please Print Clearly) 1. Name (Last, First, Middle Initial) 2. Sex 3. Social Security Number Male 4. Date of Birth 5. Date of Death Female 6. Was an autopsy performed on the employee? YES - List Medical Facility: Month Day Year Month Day Year NO DON’T KNOW Survivor Information (Please Print Clearly) 7. Name .

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