Declaration In Support Of Petition To Establish Fact Time And Place Of Death {MC-360A}

MC-360A ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): 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 FACT, TIME, AND PLACE OF DEATH (Name of declarant): HEARING DATE AND TIME: DEPT.: declares as follows: 1. I make the statements in this declaration based on my personal knowledge or on the contents of the documents identified in item 5. ("Personal knowledge" of a fact is knowledge that is not gained from another person's statements to you about that fact.) 2. a. I am at least 18 years of age. b. I reside at (street address and city): County: 3. (Name of deceased person): approximately (time): b. c. County: State or province: a.m. p.m. on (date): State: died at at the following place: State (U.S.): Country: a. City, town, township, or other (identify "other" if known): 4. Facts showing how, when, and where the person named in item 3 died and explaining how I have personal knowledge of those facts are stated in Attachment 4 to this declaration. 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.) Page 1 of 2 Form Approved by the Judicial Council of California MC-360A [Rev. July 1, 2012] Mandatory Form [7/1/2012] DECLARATION IN SUPPORT OF PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH (Miscellaneous) Health & Safety Code, §§ 103450­103490 www.courts.ca.gov American LegalNet, Inc. www.FormsWorkFlow.com MC­360A IN THE MATTER OF (Name): CASE NUMBER: 5. a. Attached are true and correct copies of the following documents (check each box that applies): Police report dated (date of each): b. c. d. Coroner's report dated (date): Private physician's report dated (date of each): Other documents dated (describe and give the date of each document): Continued on Attachment 5d. is not is important to a court case or 6. The death of the person named in item 3, or the date, time, or place of death proceeding that is pending and described below. (If you selected "is," briefly describe the proceeding and provide the case name and number, the name and address of the court where the proceeding is pending, the names of all parties to the proceeding, and the names, addresses, and telephone numbers of their attorneys. Note: A court order made on a petition under Health and Safety Code section 103450, et seq., may not be effective against claims of persons or organizations not given notice of the petition for the order.) Continued on Attachment 6. 7. 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) MC-360A [Rev. July 1, 2012] (SIGNATURE OF DECLARANT) Page 2 of 2 DECLARATION IN SUPPORT OF PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH (Miscellaneous)