COURT
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: Index No.
MC-360A
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): : Calendar No. FOR COURT USE ONLY
:
TELEPHONE NO.: Plaintiff(s)
FAX NO. (Optional):
JUDICIAL SUBPOENA
E-MAIL ADDRESS (Optional): -against- :
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF :
STREET ADDRESS:
MAILING ADDRESS: :
CITY AND ZIP CODE:
BRANCH NAME: Defendant(s) :
......................................................
IN THE MATTER OF (Name):
CASE NUMBER:
THE PEOPLE OF THE OF PETITION TO ESTABLISH RECORD OF DEATH
DECLARATION IN SUPPORTSTATE OF NEW YORK
1. (Name of declarant):
TO makes the statements in this declaration based on personal
knowledge or on the contents of the documents identified in item 5.
2. a. I am at least 18 years of age.
b. I reside at (street address and city):
GREETINGS:
County of , State of
3. WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
(Name of deceased person):
the Honorable
died at approximately (time of death): at the Court
on (date): ,
in the County of
County of located at , State of
4. , on and the of
Facts showing how, when, the where day deceased person 20
in room , item I have personal knowledge of
, named inat 3 died and explaining how noon, and at any recessed
o'clock in the
witness in Attachment on this declaration.
or adjourned date,stated in theand give evidence as aare stated in this action 4 tothe part of the
them are to testify space below
(If you are relying solely on the contents of the documents identified in item 5, please advise in the space below.)
Your failure to comply 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
result of your failure to comply.
5. Attached are true and correct copies of the following documents (check each box that applies):
a. Witness, Honorable
Police report dated (date of each): , one of the Justices of the
Court in
b.
County, day of , 20
Coroner's report dated (date):
c. Private physician's report dated (date of each):
d. (Attorney must sign above Attachment 5d if necessary.):
Other documents dated (Describe and give the date of each document. Complete on and type name below)
Attorney(s) for
6. The death of the deceased person named in item 3, or its date, time, or place, is important to litigation that is now pending
and described in Attachment 6 to this declaration. (Describe the litigation and provide the case name and number, the
name and address of the court where it is pending, and the names of all parties to the litigation and their attorneys.)
7. Number of pages attached: Office and P.O. Address
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
Telephone No.:
(TYPE OR PRINT NAME OF DECLARANT)
Facsimile No.:
(SIGNATURE OF DECLARANT)
E-Mail Address: Page 1 of 1
Form Approved for Optional Use Health & Safety Code,
Judicial Council of California Mobile Tel. No.:
DECLARATION IN SUPPORT OF PETITION TO ESTABLISH RECORD OF DEATH §§ 103450–103490
MC-360A [New January 1, 2004]
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