BMD-003 - Petition to Establish Fact, Date, and Place of Death

Summary

Petition to Establish Fact, Date, and Place of Death

Text

Form ID: BMD-003
Title: Petition to Establish Fact, Date, and Place of Death
Effective Date: 2018-09-01
Mandatory Form: yes
Info Page: https://selfhelp.courts.ca.gov/jcc-form/BMD-003
Primary Download URL: https://www.courts.ca.gov/documents/bmd003.pdf
Form Detail Page:
Petition to Establish Fact, Date, and Place of Death
(BMD-003)
Ask the court for a decision (order) establishing the fact, date, and place of a death when no record of the death was made before or you cannot get a record of the death.
Get form BMD-003
Effective: September 1, 2018
PDF Text:
Page 1 of 2
Form Adopted for Mandatory Use 
Judicial Council of California 
BMD-003 [Rev. September 1, 2018]
PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH Health and Safety Code, 
§§ 103450–103490 
www.courts.ca.gov
BMD-003
FOR COURT USE ONLY
CASE NUMBER:
HEARING DATE AND TIME: DEPT.:
ATTORNEY OR PARTY WITHOUT ATTORNEY: STATE BAR NUMBER:
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 (name):
PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH
Notice to Petitioners 
At or before the court hearing on this petition, you must provide to the court a completed (filled-in) order for the judicial officer to sign. 
The order must be prepared on a form issued by the California Department of Public Health Vital Records (CDPH Vital Records), the 
Order Establishing Fact of Death (form VS 109). The top portion of that form is the court order. The bottom portion of that form is the 
death certificate you must submit for filing to CDPH Vital Records with a copy of the signed order certified by the clerk of the court. 
Form VS 109 may be obtained from CDPH Vital Records or from a county recorder or health department. Information about the form, 
including instructions on how to get it and how to complete and file it with the court and with CDPH Vital Records, is available online 
at www.cdph.ca.gov/certlic/birthdeathmar/Pages/CorrectingorAmendingVitalRecords.aspx.
1. a. Petitioner (name each): 
is beneficially interested in and entitled under section 103450 of the California Health and Safety Code to an order establishing 
the fact and the time and place of the death of the person named in item 2a.
b.  Petitioner's beneficial interest in this matter is as follows:
(1) I am related to the person named in item 2a as follows (specify the relationships of all petitioners to that person):
(2) I am not related to the person named in item 2a.
(3) I am interested in this matter for the following reasons (complete unless item 1b(1) is selected):
Continued in Attachment 1b(3). 
2. Petitioner requests the court to establish the fact, time, and place of the death of the person named in item 2a.
a.    Name:
b. Time of death: (date and time of day): a.m. p.m.
c. Place of death:  City, town, township, or other (identify “other” if known):
(1) County:  State (U.S.): 
(2) State or province: Country:

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BMD-003 [Rev. September 1, 2018] PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH Page 2 of 2
BMD-003
CASE NUMBER:IN THE MATTER OF (name):
3. (Check one of the following):
a. There is no official record of the fact, time, and place of the death of the person named in item 2a. 
b. A certified copy of the official record of the death of the person named in item 2a cannot be obtained for the following 
reasons:
Continued in Attachment 3b.
4.  The person named in item 2a resided at the time of death at (street address and city):
County:  State:
5.  Petitioner requests that the court make an order determining that the death of the person named in item 2a did in fact occur at the 
time and at the place stated in items 2c and 2d, as shown by the Declaration in Support of Petition to Establish Fact, Time, and 
Place of Death (form BMD-003A) and attachments, filed herewith, and by other proofs adduced at the hearing.
6. Number of pages attached:
Date: 
(TYPE OR PRINT NAME OF ATTORNEY FOR PETITIONER)
 (SIGNATURE OF ATTORNEY)
I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct, except as to those 
matters stated on information and belief, and as to those matters, I am informed and believe them to be true. 
Date:
(TYPE OR PRINT NAME OF PETITIONER)
 (SIGNATURE OF PETITIONER)
Date:
(TYPE OR PRINT NAME OF PETITIONER)
 (SIGNATURE OF PETITIONER)
Date:
(TYPE OR PRINT NAME OF PETITIONER)
 (SIGNATURE OF PETITIONER)

Retrieval chunks

• #1

  Form ID: BMD-003 Title: Petition to Establish Fact, Date, and Place of Death Effective Date: 2018-09-01 Mandatory Form: yes Info Page: https://selfhelp.courts.ca.gov/jcc-form/BMD-003 Primary Download URL: https://www.courts.ca.gov/documents/bmd003.pdf Form Detail Page: Petition to Establish Fact, Date, and Plac…

• #2

  (1) I am related to the person named in item 2a as follows (specify the relationships of all petitioners to that person): (2) I am not related to the person named in item 2a. (3) I am interested in this matter for the following reasons (complete unless item 1b(1) is selected): Continued in Attachment 1b(3). 2. Pet…