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Estates, taxes, children, next of kin type of decisions, etc.
Many of the rights enjoyed automatically by married couples can be approximated with additional preparations by gay and lesbian couples, but do not hold the same strength legally. So, even if a couple put both their names on a mortgage, for example, if one party dies their surviving family members can still make a legal claim to part of the estate. Or custody of a child, for that matter. Leaving it in a will can still be contested, and would require the survivor to pay substantial inheritance taxes, which surviving spouses do not.
This just occurred to me: gay and lesbian couples have no spousal privilege (protection from being forced to testify against the other) as do legally recognized married couples. I predict an upcoming Law & Order that addresses this.
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