COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : -against- Calendar No. : Plaintiff(s) E-MAIL ADDRESS (Optional): MC-360 : ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): TELEPHONE NO.: Index No. JUDICIAL SUBPOENA FOR COURT USE ONLY FAX NO. (Optional): : ATTORNEY FOR (Name): : SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: : MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: . . . . . . . . . . (Name): IN THE.MATTER OF . . . . . . Defendant(s) : ..................................... CASE NUMBER: THE PEOPLE OF TO ESTABLISHNEW 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. Petitioner (name): 1. a. 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 named in item 2. WE COMMAND YOU, that all business and excuses space belowaside, you and each of you attend before being laid b. Petitioner's beneficial interest in this matter is stated in the 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. Name: or adjourned date, to testify and give evidence as a witness in this action on the part of the b. Date of death: c. Place of death: County of , State of 3. (Check one of the following): Your no official record of the fact, subpoena is punishable of the deceased person. a. There isfailure to comply with thisdate, and place of the deathas a contempt of court and will make you liable to the party on whose behalf this subpoenaof the issuedof theadeceased person cannot be obtained for the reasons was death for maximum penalty of $50 and all damages sustained as a A certified copy of the official record b. result of your failure in the space below stated to comply. stated in Attachment 3b. 4. Witness, Honorable Court in County, day of , 20 The deceased person resided at time of death at (street address and city): , one of the Justices of the (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. Attorney(s) for 6. Number of pages attached: Date: (TYPE OR PRINT NAME OF ATTORNEY FOR PETITIONER) (SIGNATURE OF ATTORNEY) Office and is true and correct, except as to those I certify under penalty of perjury under the laws of the State of California that the foregoingP.O. Address matters stated on information and belief, and as to those matters, I am informed and believe them to be true. Date: Telephone No.: Facsimile No.:(SIGNATURE OF PETITIONER) E-Mail Address: PETITION TO ESTABLISH RECORD OF DEATH Mobile Tel. No.: (TYPE OR PRINT NAME OF PETITIONER) Form Approved for Optional Use Judicial Council of California MC-360 [New January 1, 2004] Page 1 of 1 Health and Safety Code, §§ 103450–103490 American LegalNet, Inc. www.USCourtForms.com