Government of Ontario: Ministry of Community Safety and Correctional Services

Office of the Chief Coroner

The Coroners Act – Province of Ontario

Return of Constable Concerning Jurors and Parties Notified

Re:
, deceased.

I (Constable)
of the
state that:

Pursuant to a direction to summon issued by , a Coroner,
on the (day) day of (month) 20 ,
the following persons were summoned by me to attend on the (day) day of (month) 20
at (Time) o’clock AM PM as jurors at this inquest.

a. Name
a. Address
a. Occupation
a. Jury Roll No.

b. Name
b. Address
b. Occupation
b. Jury Roll No.

c. Name
c. Address
c. Occupation
c. Jury Roll No.

d. Name
d. Address
d. Occupation
d. Jury Roll No.

e. Name
e. Address
e. Occupation
e. Jury Roll No.

2. I believe that each person so summoned is qualified to serve as a juror.

3. The following next-of-kin of the deceased person have been
notified of the date, time and place of the inquest.

a. Name
a. Address
a. Relationship to Deceased

b. Name
b. Address
b. Relationship to Deceased

c. Name
c. Address
c. Relationship to Deceased

4. The following persons who have been designated as persons with
standing at the inquest or who may be substantially and directly interested
in the inquest have also been notified of the date, time and place of the inquest.

a. Name
a. Address

b. Name
b. Address

c. Name
c. Address

d. Name
d. Address

Date (yyyy/mm/dd)
Constable

Personal information contained on this form is collected under the authority of the Coroners Act, R.S.O. 1990, C. C.37, as amended. Questions about this collection should be directed to the Chief Coroner, 25 Morton Shulman Avenue, Toronto ON M3M 0B1, Tel.: 416 314-4000 or Toll Free: 1 877 991-9959.