Fresno — (BMD-003A) Declaration in Support of Petition for Fact of Death

Source: https://www.courts.ca.gov/documents/bmd003a.pdf

BMD-003A ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER: FOR COURT USE ONLY NAME: FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: FAX NO.: E-MAIL ADDRESS: ATTORNEY FOR (name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME:

IN THE MATTER OF (names): CASE NUMBER:

DECLARATION IN SUPPORT OF PETITION HEARING DATE AND TIME: DEPT.:
TO ESTABLISH FACT, TIME, AND PLACE OF DEATH

(Name of declarant): 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: State:

3. (Names of deceased person): died at approximately (time): a.m. p.m. on (date): at the following place:

   a. City, town, township, or other (identify “other” if known): b. County: State (U.S.):

   c. State or province: Country:

4. Facts showing when and where the person named in item 3 died and explaining how I have personal knowledge of those facts are stated in the space below are stated in Attachment 4 to this declaration. (If you are relying solely on the contents of the documents identified in item 5, please advise in the space below.)

Form Adopted for Mandatory Judicial Council of California Use DECLARATION IN SUPPORT OF PETITION TO Health & Safety Code, §§www.courts.ca.gov103450–103490 BMD-003A [Rev. September 1, 2018] ESTABLISH FACT, TIME, AND PLACE OF DEATH

BMD-003A IN THE MATTER OF (name): CASE NUMBER:

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

   a. Police report dated (date of each):

   b. Coroner's report dated (date): c. Private physician's report dated (date of each):

   d. Other documents dated (describe and give the date of each document; “Other documents” could include school or college records, vaccination certificates and other medical records, employment records, documents showing sources of support other than employment, family correspondence, diaries, photographs, and other similar family records): Continued on Attachment 5d.

6. The death of the person named in item 3, or the date, time, or place of death is not is important to a court case or proceeding that is now 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) (SIGNATURE OF DECLARANT)

BMD-003A [Rev. September 1, 2018 DECLARATION IN SUPPORT OF PETITION TO Page 2 of 2 ESTABLISH FACT, TIME, AND PLACE OF DEATH For your protection and privacy, please press the Clear button after you have printed the form. Print Save Clear