Death Testimony Questionnaire

Gathering of all victims of anti-covid injections in France and neighboring countries.

This questionnaire can help you testify on the French Victims map, in the Department where the deceased resided.

Depending on whether you do not wish to communicate all of your identity or even provide a photo or not, your testimony will take on several different appearances.

Sans Nom de famille, ni Commune, ni Photo, Témoignage de Décès :

Avec tous les renseignements d'identité et Photo, Témoignage de Décès:

From which site did you arrive here?

AAVIC TEAM

ARESAJ74

AUTRE

NAME and first name of the deceased

Relationship of the declarant to the deceased person

email of the declarant

Municipality and Department of the place of death

Date of death of the person concerned

Age of deceased

Number of doses received

Name of injections received

Batch number and injection dates

Mention the effects leading to death

Photo of the deceased

Choisissez un fichier

Formats de fichier : png, jpg, jpeg, pdf

I would like a poster to be created and distributed for Collectives and Associations

YES

I authorize the publication of the information, photo and attest to the authenticity of the information provided. Write “Good for Agreement” and write your “NAME and First name”

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