Free MC-360A DECLARATION IN SUPPORT OF PETITION TO ESTABLISH RECORD OF DEATH - California

COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. :
ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

Index No.
MC-360A

: : : : :

Calendar No.

FOR COURT USE ONLY

TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name):

FAX NO. (Optional):

Plaintiff(s)

JUDICIAL SUBPOENA

-against-

SUPERIOR COURT OF CALIFORNIA, COUNTY OF
STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE:

IN THE MATTER OF (Name):

BRANCH NAME: Defendant(s) : ......................................................

CASE NUMBER:

DECLARATION IN SUPPORTSTATE OF NEW YORK THE PEOPLE OF THE OF PETITION TO ESTABLISH RECORD OF DEATH 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:
3. County of , State of WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before (Name of deceased person): the Honorable at the Court died at approximately (time of death): on (date): located at County of in the County of , State of Facts showing how, when, the where day deceased person 20 the of I have personal knowledge of in room , on and , named inat 3 died and explaining how noon, and at any recessed , item o'clock in the them are to testify space below or adjourned date,stated in theand give evidence as aare stated in this action 4 tothe part of the witness in Attachment on this declaration. (If you are relying solely on the contents of the documents identified in item 5, please advise in the space below.)

,

4.

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. a. Attached are true and correct copies of the following documents (check each box that applies):

Witness, Honorable Police report dated (date of each):
Coroner's report dated (date):

, one of the Justices of the , 20

Court in b.
c. d.

County,

day of

Private physician's report dated (date of each):
(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.) Number of pages attached:

7.

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:

MC-360A [New January 1, 2004]

Telephone No.: Facsimile No.: (TYPE OR PRINT NAME OF DECLARANT) (SIGNATURE OF DECLARANT) E-Mail Address: Form Approved for Optional Use Mobile Tel. No.: Judicial Council of California DECLARATION IN SUPPORT OF PETITION TO ESTABLISH RECORD OF DEATH

Page 1 of 1 Health & Safety Code, §§ 103450­103490

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