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Here is the text we could read:

ATTORNEY OR PARTY WITHOUT ATTORNEY:

STATE BAR NUMBER:

FOR COURT USE ONLY

BMD-003

NAME:

FIRM NAME:

STREET ADDRESS:

CITY:

TELEPHONE 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):

STATE:

FAX NO.:

ZIP CODE:

CASE NUMBER:

PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH

HEARING DATE AND TIME:

DEPT.:

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):

I am not related to the person named in item 2a.

(2)

(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.

Time of death: (date and time of day):

a.m.

p.m.

Place of death:  City, town, township, or other (identify “other” if known):

a.    

Name:

b.

c.

(1)

(2)

County: 

State or province:

 State (U.S.): 

Country:

Form Adopted for Mandatory Use 
Judicial Council of California 
BMD-003 [Rev. September 1, 2018]

PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH 

Page 1 of 2

Health and Safety Code, 
§§ 103450–103490 
www.courts.ca.gov

IN THE MATTER OF (name):

CASE NUMBER:

BMD-003

3.

(Check one of the following):

a.
b.

There is no official record of the fact, time, and place of the death of the person named in item 2a. 
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:

(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. 

(TYPE OR PRINT NAME OF PETITIONER)

(SIGNATURE OF PETITIONER)

(TYPE OR PRINT NAME OF PETITIONER)

(SIGNATURE OF PETITIONER)

(TYPE OR PRINT NAME OF PETITIONER)

(SIGNATURE OF PETITIONER)

BMD-003 [Rev. September 1, 2018]

PETITION TO ESTABLISH FACT, TIME, AND PLACE OF DEATH 

Page 2 of 2

Date: 

Date:

Date:

Date:

Petition to Establish Fact, Date, and Place of Death

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the California state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from selfhelp.courts.ca.gov (2023-03)
Page(s): 2
Fields(s): 56
Average fields per page: 28
Reading Level: Grade 8
LIST Grouping(s): Unknown

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

bm_page_specify_relationship was BMD-003[0].Page1[0].SpecifyRelationship[0] (0.58 conf)
bm_page_desc_interest_ft was BMD-003[0].Page1[0].DescInterest_ft[0] (0.37 conf)
bm_page_interested_reasons_f_cb was BMD-003[0].Page1[0].InterestedReasons_OF_cb[0] (0.37 conf)
bm_page_cb__1 was BMD-003[0].Page1[0].I_am_cb[0] (0.33 conf)
bm_page_interested_reasons_cb was BMD-003[0].Page1[0].InterestedReasons_cb[0] (0.35 conf)
bm_page_cb__2 was BMD-003[0].Page1[0].I_am_cb[1] (0.33 conf)
bm_page_petitioners_ft was BMD-003[0].Page1[0].Petitioners_ft[0] (0.32 conf)
bm_page_deceased_name was BMD-003[0].Page1[0].DeceasedName[0] (0.29 conf)
bm_page_time_death_ft was BMD-003[0].Page1[0].TimeOfDeath_ft[0] (0.38 conf)
bm_page_place_death_city_ft was BMD-003[0].Page1[0].PlaceOfDeathCity_ft[0] (0.37 conf)
bm_page_place_death_county_ft was BMD-003[0].Page1[0].PlaceOfDeathCounty_ft[0] (0.41 conf)
page_place_death_u_state_ft was BMD-003[0].Page1[0].PlaceOfDeathUState_ft[0] (0.44 conf)
page_place_death_state_u_ft was BMD-003[0].Page1[0].PlaceOfDeathStateNotUS_ft[0] (0.39 conf)
bm_page_place_death_country_u_ft was BMD-003[0].Page1[0].PlaceOfDeathCountryNotUS_ft[0] (0.37 conf)
page_caption_sf_crt_county_ft was BMD-003[0].Page1[0].p1Caption_sf[0].CourtInfo[0].CrtCounty_ft[0] (0.39 conf)
bm_page_p_caption_sf_court_info_branch_ft was BMD-003[0].Page1[0].p1Caption_sf[0].CourtInfo[0].Branch_ft[0] (0.36 conf)
bm_page_p_caption_sf_court_info_city_zip_ft was BMD-003[0].Page1[0].p1Caption_sf[0].CourtInfo[0].CityZip_ft[0] (0.39 conf)
bm_page_p_caption_sf_court_info_street_ft was BMD-003[0].Page1[0].p1Caption_sf[0].CourtInfo[0].Street_ft[0] (0.35 conf)
bm_page_p_caption_sf_court_info_mailing_add_ft was BMD-003[0].Page1[0].p1Caption_sf[0].CourtInfo[0].MailingAdd_ft[0] (0.37 conf)
bm_page_p_caption_sf_title_party_name_ft was BMD-003[0].Page1[0].p1Caption_sf[0].TitlePartyName[0].Party1_ft[0] (0.36 conf)
page_p_caption_sf_number_ft was BMD-003[0].Page1[0].p1Caption_sf[0].CaseNumber[0].CaseNumber_ft[0] (0.38 conf)
bm_page_p_caption_sf_atty_info_state_ft was BMD-003[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyState_ft[0] (0.37 conf)
bm_page_p_caption_sf_atty_info_zip_ft was BMD-003[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyZip_ft[0] (0.42 conf)
bm_page_p_caption_sf_atty_info_city_ft was BMD-003[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyCity_ft[0] (0.40 conf)
bm_page_p_caption_sf_atty_info_street_ft was BMD-003[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyStreet_ft[0] (0.38 conf)
bm_page_p_caption_sf_atty_info_firm_ft was BMD-003[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyFirm_ft[0] (0.45 conf)
bm_page_p_caption_sf_atty_info_name_ft was BMD-003[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyName_ft[0] (0.40 conf)
bm_page_p_caption_sf_atty_info_phone_ft was BMD-003[0].Page1[0].p1Caption_sf[0].AttyInfo[0].Phone_ft[0] (0.35 conf)
bm_page_p_caption_sf_atty_info_fax_ft was BMD-003[0].Page1[0].p1Caption_sf[0].AttyInfo[0].Fax_ft[0] (0.39 conf)
bm_page_p_caption_sf_atty_info_email_ft was BMD-003[0].Page1[0].p1Caption_sf[0].AttyInfo[0].Email_ft[0] (0.41 conf)
bm_page_p_caption_sf_atty_info_ft was BMD-003[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyFor_ft[0] (0.39 conf)
bm_page_p_caption_sf_atty_info_bar_dc was BMD-003[0].Page1[0].p1Caption_sf[0].AttyInfo[0].AttyBarNo_dc[0] (0.36 conf)
page_p_sf_hearing_time_ime__1 was BMD-003[0].Page1[0].p1Caption_sf[0].HearingDateTime_sf[0].HearingDateTIme_ft[0] (0.46 conf)
page_p_sf_hearing_time_ime__2 was BMD-003[0].Page1[0].p1Caption_sf[0].HearingDateTime_sf[1].HearingDateTIme_ft[0] (0.46 conf)
bm_page_b_time_choice_cb__1 was BMD-003[0].Page1[0].ToBTimeChoice_cb[0] (0.36 conf)
bm_page_b_time_choice_cb__2 was BMD-003[0].Page1[0].ToBTimeChoice_cb[1] (0.36 conf)
bm_page_checkbox__1 was BMD-003[0].Page1[0].Checkbox[0] (0.31 conf)
bm_page_checkbox__2 was BMD-003[0].Page1[0].Checkbox[1] (0.31 conf)
bm_page_px_caption_sf_case_number was BMD-003[0].Page2[0].PxCaption_sf[0].CaseNumber[0].CaseNumber[0] (0.38 conf)
bm_page_px_caption_sf_title_party_name_ft was BMD-003[0].Page2[0].PxCaption_sf[0].TitlePartyName[0].Party1_ft[0] (0.36 conf)
bm_page_cert_copy_reasons was BMD-003[0].Page2[0].NoCertCopyReasons[0] (0.44 conf)
page_deceased_residence_address was BMD-003[0].Page2[0].DeceasedResidenceAddress[0] (0.37 conf)
bm_page_deceased_residence_county was BMD-003[0].Page2[0].DeceasedResidenceCounty[0] (0.37 conf)
page_deceased_residence_state was BMD-003[0].Page2[0].DeceasedResidenceState[0] (0.37 conf)
bm_page_pages_attached was BMD-003[0].Page2[0].PagesAttached[0] (0.35 conf)
bm_page_petitioner_attorney_sig_date was BMD-003[0].Page2[0].PetitionerAttorneySigDate[0] (0.41 conf)
page_petitioner_attorney_sig_name was BMD-003[0].Page2[0].PetitionerAttorneySigName[0] (0.41 conf)
bm_page_petitioner_sig_date__1 was BMD-003[0].Page2[0].PetitionerSigDate1[0] (0.38 conf)
bm_page_petitioner_sig__1 was BMD-003[0].Page2[0].PetitionerSig1[0] (0.32 conf)
bm_page_petitioner_sig_date__2 was BMD-003[0].Page2[0].PetitionerSigDate2[0] (0.38 conf)
bm_page_petitioner_sig__2 was BMD-003[0].Page2[0].PetitionerSig2[0] (0.32 conf)
bm_page_petitioner_sig_date__3 was BMD-003[0].Page2[0].PetitionerSigDate3[0] (0.38 conf)
bm_page_petitioner_sig__3 was BMD-003[0].Page2[0].PetitionerSig3[0] (0.32 conf)
bm_page_death_record_reasons_f_cb was BMD-003[0].Page2[0].NoDeathRecordReasons_OF_cb[0] (0.34 conf)
bm_page_record_cb__1 was BMD-003[0].Page2[0].No_record_cb[0] (0.30 conf)
bm_page_record_cb__2 was BMD-003[0].Page2[0].No_record_cb[1] (0.30 conf)

We've done our best to group similar variables togther to avoid overwhelming the user.

Suggested Screen 0:

bm_page_desc_interest_ft
bm_page_interested_reasons_f_cb
bm_page_interested_reasons_cb
bm_page_death_record_reasons_f_cb

Suggested Screen 1:

bm_page_cb__1
bm_page_cb__2
bm_page_b_time_choice_cb__1
bm_page_b_time_choice_cb__2
bm_page_record_cb__1
bm_page_record_cb__2

Suggested Screen 2:

bm_page_deceased_name
bm_page_time_death_ft
bm_page_place_death_city_ft
bm_page_place_death_county_ft
bm_page_deceased_residence_county

Suggested Screen 3:

page_place_death_u_state_ft
page_place_death_state_u_ft
bm_page_place_death_country_u_ft

Suggested Screen 4:

page_caption_sf_crt_county_ft
bm_page_p_caption_sf_court_info_branch_ft
bm_page_p_caption_sf_court_info_city_zip_ft
bm_page_p_caption_sf_court_info_street_ft
bm_page_p_caption_sf_court_info_mailing_add_ft
bm_page_p_caption_sf_title_party_name_ft
page_p_caption_sf_number_ft
bm_page_p_caption_sf_atty_info_state_ft
bm_page_p_caption_sf_atty_info_zip_ft
bm_page_p_caption_sf_atty_info_city_ft
bm_page_p_caption_sf_atty_info_street_ft
bm_page_p_caption_sf_atty_info_firm_ft
bm_page_p_caption_sf_atty_info_name_ft
bm_page_p_caption_sf_atty_info_phone_ft
bm_page_p_caption_sf_atty_info_fax_ft
bm_page_p_caption_sf_atty_info_email_ft
bm_page_p_caption_sf_atty_info_ft
bm_page_p_caption_sf_atty_info_bar_dc
bm_page_px_caption_sf_case_number
bm_page_px_caption_sf_title_party_name_ft

Suggested Screen 5:

page_p_sf_hearing_time_ime__1
page_p_sf_hearing_time_ime__2

Suggested Screen 6:

bm_page_checkbox__1
bm_page_checkbox__2

Suggested Screen 7:

bm_page_cert_copy_reasons

Suggested Screen 8:

page_deceased_residence_address
page_deceased_residence_state

Suggested Screen 9:

bm_page_pages_attached

Suggested Screen 10:

page_petitioner_attorney_sig_name

Suggested Screen 11:

bm_page_specify_relationship
bm_page_petitioners_ft
bm_page_petitioner_attorney_sig_date
bm_page_petitioner_sig_date__1
bm_page_petitioner_sig__1
bm_page_petitioner_sig_date__2
bm_page_petitioner_sig__2
bm_page_petitioner_sig_date__3
bm_page_petitioner_sig__3

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Petition to Establish Fact, Date, and Place of Death

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02