Government of Ontario: Ministry of Community Safety and Correctional Services

Office of the Chief Coroner

Affidavit of Service of Summons

The Coroners Act – Province of Ontario

I
, of the of in the of , (Occupation) make oath/affirmation and say that I did on the (day) day of (month) 20 serve (Print Name) with a true copy of the attached summons.

Strike out inapplicable clause

personal service by delivering said summons to (Name) at (Address) , or
by leaving a copy, in a sealed envelope addressed to the person summoned, at his or her place or residence with (Name) who appeared to be an adult member of the same household, or
by sending the same registered mail addressed to the place of residence of the person summoned
at
(Signature)

Sworn before me this (day) day of (month) 20

At the of
in the of

A Commissioner, etc.