Declaration In Support Of Petition To Establish Record Of Death
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Declaration In Support Of Petition To Establish Record Of Death Form. This is a California form and can be use in Miscellaneous Judicial Council.
Tags: Declaration In Support Of Petition To Establish Record Of Death, MC-360A, California Judicial Council, Miscellaneous
MC-360A
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):
TELEPHONE NO.:
FOR COURT USE ONLY
FAX NO. (Optional):
E-MAIL ADDRESS (Optional):
ATTORNEY FOR (Name):
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS:
MAILING ADDRESS:
CITY AND ZIP CODE:
BRANCH NAME:
IN THE MATTER OF (Name):
CASE NUMBER:
DECLARATION IN SUPPORT OF PETITION TO ESTABLISH RECORD OF DEATH
1.
(Name of declarant):
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):
3.
4.
County of
, State of
(Name of deceased person):
died at approximately (time of death):
on (date):
in the County of
, State of
Facts showing how, when, and where the deceased person named in item 3 died and explaining how I have personal knowledge of
are stated in Attachment 4 to this declaration.
them
are stated in the space below
(If you are relying solely on the contents of the documents identified in item 5, please advise in the space below.)
5.
Attached are true and correct copies of the following documents (check each box that applies):
a.
b.
Private physician's report dated (date of each):
d.
7.
Coroner's report dated (date):
c.
6.
Police report dated (date of each):
Other documents dated (Describe and give the date of each document. Complete on Attachment 5d if necessary.):
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.)
Number of pages attached:
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Date:
(TYPE OR PRINT NAME OF DECLARANT)
(SIGNATURE OF DECLARANT)
Page 1 of 1
Form Approved for Optional Use
Judicial Council of California
MC-360A [New January 1, 2004]
DECLARATION IN SUPPORT OF PETITION TO ESTABLISH RECORD OF DEATH
Health & Safety Code,
§§ 103450–103490
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