Santa Clara — VS-109

Source: https://www.cdph.ca.gov/CDPH%20Document%20Library/ControlledForms/VS109.pdf

ORDER ESTABLISHING FACT OF DEATH

In the Superior Court of the State of California

In and for the County of __________________

In the matter of the petition of

_______________________________ Number __________________________

Department ________________________

To establish the fact of death of

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The verified petition of _______________________________________________________ to establish the fact of the death of

__________________________________________________________________________________ having been filed herein on the

___________ day of _________________, A.D., 20, and such petition having by an order of court been duly set for

hearing on the ___________ day of _____________, A.D., 20, at the hour of __________ o’clock _____ m. of said

day; and now on said day said matter coming on regularly for hearing and it appearing to the satisfaction of this court from the evidence

introduced that the said _______________________________________________________________, petitioner herein, is beneficially

interested in establishing of record the fact of the death of said _________________________________________________________,

in that ______________________________________________________________________________________________________

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______________________________________________; and it appearing that on the ___________ day of _____________________,

A.D., 20________, the death of _________________________________________________________________________ occurred at

_______________________________________________, in the County of ________________________________________, State of

___________________________________________; that said death has not been registered in conformity with the provisions of law in

effect at the time of said death or such record has been lost or destroyed after having been filed; and no one appearing at said hearing to

oppose the making of this order;

It is therefore ordered, adjudged, and decreed that on the ____________ day of __________________________________, A.D.,

20________, the death of ________________________________________________________________________________________

occurred at ____________________________________________________, County of ______________________________________,

State of __________________________________.

Done in court this ___________ day of ______________, A.D., 20.

►___________________________________________________ Judge of the Superior Court

Before filing the above order, insert in the certificate form below, as of the date of the death, the personal and statistical particulars required for the records of the State Registrar. A certified copy of the above order must be filed with the State Registrar before the order shall become effective. USE BLACK INK ONLY.

STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, OFFICE OF VITAL RECORDS FORM VS 109 (Rev. 04/20)

COURT ORDER DELAYED REGISTRATION OF DEATH STATE OF CALIFORNIA

NO ERASURES, WHITEOUTS, PHOTOCOPIES,

______________________________________ OR ALTERATIONS _ _____________________________________ STATE FILE NUMBER LOCAL REGISTRATION NUMBER

TYPE OR PRINT CLEARLY IN BLACK INK ONLY – THIS FORM BECOMES THE OFFICIAL DEATH RECORD

1A. NAME—FIRST 1B. MIDDLE 1C. LAST

2A. DATE OF DEATH—MM/DD/CCYY 2B. HOUR 3. DATE OF BIRTH—MM/DD/CCYY 4. AGE IN YEARS IF UNDER ONE YEAR IF UNDER 24 HOURS
MONTHS DAYS HOURS MINUTES

5. BIRTH STATE/FOREIGN 6. HISPANIC (IF YES, SPECIFY ORIGIN) 7. RACE—Up to 3 Races/Ethnicities May Be Listed 8. SEX
COUNTRY
YES □________________ NO □

9. MILITARY SERVICE? 10. SOCIAL SECURITY NUMBER 11. EDUCATION—YEARS COMPLETED 12. MARITAL/STATE REGISTERED

DECEDENT DOMESTIC PARTNERSHIP STATUS PERSONAL YES □ NO □ UNK □ DATA 13A. USUAL OCCUPATION 13B. USUAL KIND OF BUSINESS/INDUSTRY 13C. USUAL EMPLOYER 13D. YEARS IN OCCUPATION

14A. NAME OF SURVIVING SPOUSE/STATE REGISTERED 14B. MIDDLE 14C. LAST (BIRTH)
DOMESTIC PARTNER--FIRST

15A. NAME OF FATHER/PARENT--FIRST 15B. MIDDLE 15C. LAST (BIRTH) 16. STATE/FOREIGN
COUNTRY OF BIRTH

17A. NAME OF MOTHER/PARENT—FIRST 17B. MIDDLE 17C. LAST (BIRTH) 18. STATE/FOREIGN
COUNTRY OF BIRTH

19A. RESIDENCE—STREET and NUMBER, OR LOCATION 19B. CITY 19C. STATE/FOREIGN COUNTRY 19D. ZIP CODE

USUAL

RESIDENCE 19E. COUNTY 19F. NUMBER OF YEARS IN THIS COUNTY 20. NAME, RELATIONSHIP, MAILING ADDRESS, AND ZIP CODE OF INFORMANT

21A. PLACE OF DEATH 21B. COUNTY

21C. ADDRESS—STREET and NUMBER, OR LOCATION 21D. CITY PLACE OF DEATH 21E. IF HOSPITAL, SPECIFY 21F. IF OTHER THAN HOSPITAL, SPECIFY □IP □ER/OP □DOA □HOSPICE □ NURSING HOME/LTC □HOME □ OTHER TIME INTERVAL 23. DEATH REPORTED TO CORONER? BETWEEN ONSET 22. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER LINE FOR A, B, AND C) AND DEATH □YES __________________ □ NO REFERRAL NUMBER 24. BIOPSY PERFORMED?

IMMEDIATE □YES __________________ □NO
CAUSE (A)
25A. AUTOPSY PERFORMED?
□YES __________________ □NO DUE TO (B)

CAUSE OF 25B. USED IN DETERMINING CAUSE? DEATH □YES __________________ □NO DUE TO (C) 26. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO 27. WAS OPERATION PERFORMED FOR ANY CONDITION IN 28. IF FEMALE, PREGNANT IN YEAR DEATH BUT NOT RELATED TO CAUSE GIVEN IN ITEM 22. ITEM 22 OR 26? IF YES, LIST TYPE OF OPERATION AND DATE. PRIOR TO DEATH? □YES __________________ □NO

29. LOCATION—STREET AND NUMBER, OR LOCATION, AND CITY 30. DESCRIBE HOW INJURY OCCURRED (EVENTS WHICH RESULTED IN INJURY)
INJURY

INFORMATION

31A. DISPOSITION(S) 31B. PLACE OF FINAL DISPOSITION (NAME AND FULL ADDRESS) 31C. DATE OF DISPOSITION—MM/DD/CCYY

FUNERAL DIRECTOR 32A. NAME OF FUNERAL ESTABLISHMENT (OR PERSON ACTING IN LIEU OF FUNERAL DIRECTOR) 32B. LICENSE NUMBER

OFFERED FOR FILING PURSUANT TO ORDER NUMBER ___________________________OF THE SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF

_________________________________, MADE THE __________ DAY OF ________________, A.D., 20, ESTABLISHING OF RECORD THE FACT OF DEATH IN THE

STATE STATE OR COUNTRY OF _____________________________________. NO DEATH CERTIFICATE HAS BEEN FOUND ON FILE IN THE OFFICE OF VITAL RECORDS FOR THE

REGISTRAR USE ONLY ABOVE DECEDENT.

33. OFFICE OF VITAL RECORDS 34. DATE ACCEPTED FOR REGISTRATION

STATE OF CALIFORNIA, DEPARTMENT OF PUBLIC HEALTH, OFFICE OF VITAL RECORDS FORM VS 109 (Rev. 04/20)