Free ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address) - California

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, state bar number, and address)

FOR COURT USE ONLY

TELEPHONE NO: ATTORNEY FOR (NAME):

FAX NO:

SUPERIOR COURT OF CALIFORNIA COUNTY OF YUBA 215 FIFTH STREET, SUITE 200 MARYSVILLE, CA 95901 (530) 749-7600 IN THE MATTER OF THE PETITION OF: TO ESTABLISH THE FACT OF DEATH OF:

ORDER ESTABLISHING FACT OF DEATH [H&S § 103450]

CASE NUMBER:

THE COURT FINDS as follows: 1. 2. Petitioner is a resident of the County of Yuba, State of California. _______________________ became deceased on ________________________________ [ County of __________________________, State of __________________________ or [ Country of ____________________________________. 3. Said death was not registered in conformity with the provisions of law in effect at the time of said death, or such record was lost or destroyed after having been filed. THE COURT ORDERS that the death of _______________________ which occurred as set forth hereinabove, is hereby verified and established by this Court. Dated: ____________________ JUDGE OF THE SUPERIOR COURT ] in the ] in the

Yuba County Superior Court Effective 8/10/05

ORDER ESTABLISHING FACT OF DEATH

PR05013

[H&S § 103450]