MC-360 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: CASE NUMBER: IN THE MATTER OF (Name): HEARING DATE AND TIME: DEPT.: PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH Notice to Petitioners At or before the court hearing on this petition, you must provide to the court a completed (filled-in) order for the judicial officer to sign. The order must be prepared on a form issued by the California Department of Public Health Vital Records (CDPH Vital Records), the Order Establishing Fact of Death (form VS 109). The top portion of that form is the court order. The bottom portion of that form is the death certificate you must submit for filing to CDPH Vital Records with a copy of the signed order certified by the clerk of the court. Form VS 109 may be obtained from CDPH Vital Records or from a county recorder or health department. Information about the form, including instructions on how to get it and how to complete and file it with the court and with CDPH Vital Records, is available online at www.cdph.ca.gov/certlic/birthdeathmar/Pages/CorrectingorAmendingVitalRecords.aspx. 1. a. Petitioner (name each): is beneficially interested in and entitled under section 103450 of the California Health and Safety Code to an order establishing the fact and the time and place of the death of the person named in item 2a. b. Petitioner's beneficial interest in this matter is as follows: (1) I am related to the person named in item 2a as follows (specify the relationships of all petitioners to that person): (2) I am not related to the person named in item 2a. (3) I am interested in this matter for the following reasons (complete in all cases): Continued in Attachment 1b(3). 2. Petitioner requests the court to establish the fact, time, and place of the death of the person named in item 2a. a. Name: b. Time of death (date and time of day): a.m. p.m. c. Place of death: City, town, township, or other (identify “other” if known): (1) County: (2) State or province: State (U.S.): Country: Page 1 of 2 Form Approved by the Judicial Council of California MC-360 [Rev. July 1, 2012] Mandatory Form [7/1/2012] PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH (Miscellaneous) Health and Safety Code, §§ 103450–103490 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com MC–360 IN THE MATTER OF CASE NUMBER: (Name): 3. (Check one of the following): a. There is no official record of the fact, time, and place of the death of the person named in item 2a. b. A certified copy of the official record of the death of the person named in item 2a cannot be obtained for the following reasons: Continued in Attachment 3b. 4. The person named in item 2a resided at the time of death at (street address and city): County: State: 5. Petitioner requests that the court make an order determining that the death of the person named in item 2a did in fact occur on the time and at the place stated in items 2b and 2c, as shown by the Declaration in Support of Petition to Establish Fact, Time, and Place of Death (form MC-360A) and attachments, filed herewith, and by other proofs adduced at the hearing. 6. Number of pages attached: Date: (SIGNATURE OF ATTORNEY) (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: (TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER) (TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER) (TYPE OR PRINT NAME OF PETITIONER) (SIGNATURE OF PETITIONER) Date: Date: MC-360 [Rev. July 1, 2012] PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH (Miscellaneous) Page 2 of 2