COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. :
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Index No. Calendar No.
MC-360
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Defendant(s) BRANCH NAME: : . . MATTER .OF. (Name): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ...... . ..... IN THE
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THE PEOPLE OFTO ESTABLISH NEW YORK DEATH PETITION THE STATE OF RECORD OF TO Notice: At or before the hearing on this petition, the petitioner must provide an order for the judge to sign. The order is part of form VS 109, issued by the Office of Vital Records, California Department of Health Services. Form VS 109 may be obtained from that department, or from a county recorder or health department. Information about form VS 109, including instructions on how to get it, and how to complete and file it, is available online at www.dhs.ca.gov/hisp/chs/OVR/Amendments/Amendmentindex.htm.
1. a. Petitioner (name): GREETINGS: is a beneficially interested person, entitled under section 103450 of the California Health and Safety Code to an order establishing the fact and the date and place of the death of the deceased person that allin item 2. and excuses being laid aside, you and each of you attend before WE COMMAND YOU, named business stated in the space below Petitioner's beneficial interest in this matter is stated in Attachment 1b.
, the Honorable at the Court located at County of 2. Deceased person: in room , on the day of , 20 , at o'clock in the noon, and at any recessed a. or adjourned date, to testify and give evidence as a witness in this action on the part of the Name:
b. Date of death: c. Place of death: County of , State of
b.
3. (Check one of the following): Your no official comply the fact, date, and place of the death of the deceased person. a. There is failure to record of with this subpoena is punishable as a contempt of court and
will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a A certified copy of the official record of the death of the deceased person cannot be obtained for the reasons b. result of your failurein the space below stated to comply. stated in Attachment 3b. Witness, Honorable County, , one of the Justices of the day of , 20
4. The deceased person resided at time of death at (street address and city):
Court in
6. Number of pages attached: Date:
(Attorney must sign above and type name below) County of , State of 5. Petitioner requests that the court make an order determining that the death of the deceased person did in fact occur on the date and at the place stated in item 2 above, as shown by the form MC-360A, Declaration in Support of Petition to Establish Record of Death and attachments, filed herewith, and by other proofs adduced at the hearing. for Attorney(s)
(TYPE OR PRINT NAME OF ATTORNEY FOR PETITIONER)
I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct, except as to those matters stated on information and belief, and as to those matters, I am informed and believe them to be true. Date:
Office and P.O. Address
(SIGNATURE OF ATTORNEY)
Telephone No.: Facsimile No.:(SIGNATURE OF PETITIONER) (TYPE OR PRINT NAME OF PETITIONER) E-Mail Address: Form Approved for Optional Use Mobile DEATH PETITION TO ESTABLISH RECORD OFTel. No.: Judicial Council of California
MC-360 [New January 1, 2004]
Page 1 of 1 Health and Safety Code, §§ 103450–103490
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