ࡱ>  @ YbjbjPP ::#0Q@@@4t999h@::tkt< ????A9D\EJ^L^L^L^-y^Idj$xlRnx=j@LYA@ALL=j??jOOOLj8?@?J^OLJ^OO:T,(@*U?< N\9LT FWj0kTRBoxMBo*UttBo@*UEFHGOwH3IEFEFEF=j=jttd59DOjtt9 SEQ CHAPTER \h \r 1EIGHTH JUDICIAL DISTRICT COURT CLARK COUNTY, NEVADA FAMILY COURT COVER SHEET CASE NO.  FORMTEXT       (To be assigned by the Clerk s Office) Do you or any other party in this case (including any minor child) have any other current case(s) or past case(s) in the Family Court or Juvenile Court in Clark County?  FORMCHECKBOX  YES  FORMCHECKBOX  NO If yes, complete the other side of this form PARTY INFORMATION (Please Print) Plaintiff/PetitionerDefendant/Respondent/Co-Petitioner/Ward/DecedentLast Name:Last Name:First Name:Middle Name:First Name:Middle Name:Home Address:Home Address:City, State, Zip:City, State, Zip:Mailing Address: FORMTEXT      Mailing Address: FORMTEXT      City, State, Zip: FORMTEXT      City, State, Zip: FORMTEXT      Phone #:Date of Birth:Phone #:Date of Birth:Attorney InformationAttorney InformationName:Bar No.Name:Bar No: Address:Address:City, State, Zip:City, State, Zip:Phone #:Phone #: (Check one box only for the type of case being filed with this cover sheet) DOMESTICMISC. DOMESTIC RELATIONS PETITIONSGUARDIANSHIPPROBATEMarriage Dissolution  FORMCHECKBOX  Annulment  FORMCHECKBOX  Divorce No minor child(ren)  FORMCHECKBOX  Divorce With minor child(ren)  FORMCHECKBOX  Foreign Decree  FORMCHECKBOX  Joint Petition No minor child(ren)  FORMCHECKBOX  Joint Petition With minor child(ren)  FORMCHECKBOX  Separate Maintenance FORMCHECKBOX  Adoption Minor  FORMCHECKBOX  Adoption Adult  FORMCHECKBOX  Mental Health  FORMCHECKBOX  Name Change  FORMCHECKBOX  Paternity  FORMCHECKBOX  Permission to Marry  FORMCHECKBOX  Temporary Protective Order (TPO)  FORMCHECKBOX  Termination of Parental Rights  FORMCHECKBOX  Child Support/Custody  FORMCHECKBOX  Other (identify) __________________Guardianship of an Adult  FORMCHECKBOX  Person  FORMCHECKBOX  Estate  FORMCHECKBOX  Person and Estate Guardianship of a Minor  FORMCHECKBOX  Person  FORMCHECKBOX  Estate  FORMCHECKBOX  Person and Estate  FORMCHECKBOX  Guardianship Trust FORMCHECKBOX  Summary Administration  FORMCHECKBOX  General Administration  FORMCHECKBOX  Special Administration  FORMCHECKBOX  Set Aside Estates  FORMCHECKBOX  Trust/Conservatorships  FORMCHECKBOX  Individual Trustee  FORMCHECKBOX  Corporate Trustee  FORMCHECKBOX  Other Probate MISC. JUVENILE PETITIONSDA CHILD SUPPORT PETITIONS FORMCHECKBOX  Emancipation  FORMCHECKBOX  DA UIFSA  FORMCHECKBOX  DA - Child Support In State List children involved in this case (If more than 3 children, please enter the information on the reverse side)Last NameFirst NameMiddle NameDate of BirthRelationship1.2.3. _________________________________ __________________________________ ________________ Printed Name of Preparer Signature of Preparer Date  Supply the following information about any other proceeding (check all that apply):  FORMCHECKBOX  Divorce  FORMCHECKBOX  Temporary Protective Orders (TPO)  FORMCHECKBOX  Custody/Child Support  FORMCHECKBOX  UIFSA/URESA  FORMCHECKBOX  Paternity  FORMCHECKBOX  Juvenile Court  FORMCHECKBOX  Other Please Print List full name of all adult parties involvedCase number of other proceeding(s)Approximate date of last order in other proceeding(s)Last NameFirst NameMiddle Name1. FORMTEXT       FORMTEXT      2. FORMTEXT       FORMTEXT      3. FORMTEXT       FORMTEXT      4. FORMTEXT       FORMTEXT      If children were involved (other than those listed on front page), please provide:Last NameFirst NameMiddle NameDate of BirthRelationship1.2.3.4.5.6.7.8.Children involved in this case (continuation from front page)Last NameFirst NameMiddle NameDate of BirthRelationship4.5.6.7.8. THIS INFORMATION IS REQUIRED BY NRS 3.025, NRS 3.223, NRS 3.227, NRS 3.275, NRS 125.130, NRS 125.230, And will be kept in a confidential manner by the Clerks Office. PET _____________________________ Name _____________________________ Address _____________________________ City, State, Zip Code _____________________________ Telephone number/E-mail Address IN PROPER PERSON DISTRICT COURT CLARK COUNTY, NEVADA In the Matter of the Estate of: Deceased.) ) ) ) ) ) ) Case No. P__________ Dept. No. PC-1 EX PARTE PETITION FOR ORDER TO RELEASE MEDICAL RECORDS Petitioner, ___________________________________________, appearing in Proper Person, respectfully alleges and shows as follows: Petitioner is the ___________________ (how related) of Decedent ________________________ (decedents name) and resides at ____________________________________________________________. Decedent died on the ____ day of ___________, 20_____, in _________________________ and, on the date of death, Decedent was a resident of Clark County, Nevada. A certified copy of Decedents death certificate will be submitted upon receipt. Jurisdiction is proper in this proceeding. The names, relationships, ages of minors and residence addresses of all the devisees, legatees, heirs, and next-of-kin of Decedent, so far as known to Petitioner, are: (Below Must Include: Legally Married Spouse And All Children, Even If Estranged or out of State And You as Petitioner Stating All Relationships, adult or minor and Addresses (if unknown put last address or unknown) Name ! Relationship/Age ! Address ! 1. 2. 3. 4. 5. 6. Petitioner is seeking medical records from (list names & addresses of all medical facilities and doctors from whom you are seeking records) ________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ WHEREFORE, Petitioner prays: That the Court make and enter its order directing the officers of (list names & addresses of all medical facilities and doctors from whom you are seeking records) ____________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ to release Decedents medical records to _______________________ ________________________________________________________________ (name and address). DATED THIS _____ day of _______________, 20___. _____________________________ Signature of Petitioner VERIFICATION STATE OF NEVADA ) )ss COUNTY OF CLARK ) ________________________, being first duly sworn, declares under penalty of perjury as follows: I am the Petitioner in the above-entitled action. I have read the foregoing Ex Parte Petition for Order to Release Medical Records, and know the contents thereof. The Petition is true of my own knowledge except as to those matters that are stated on information and belief, and as to those matters, I believe them to be true. 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ORDERED that the officers of (list names & addresses of all medical facilities and doctors from whom you are seeking records) _________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ /// /// /// shall release the Decedents medical records to ________________ _______________________________________________________________. DATED this ____ day of ___________, 20_____. _______________________________ DISTRICT COURT JUDGE Respectfully submitted, By: ___________________ (signature) ___________________ (print name) IN PROPER PERSON     USJR COVER SHEET 05/25/01 Revised 04/21/09 Nevada AOC Research & Statistics Unit Pursuant to NRS 3.275 gdu_$ ")Dd]D^a$gdu_$ ")Dd]D^a$$da$dgdxKdgdB d`gdB$&VWXYƾhy"hp45CJ\aJh:.=hUCJaJhUhUCJaJhnO@CJaJhBhUCJ OJQJ^JaJ hUCJaJhUhu_hUaJ @VWXYdgdxK4...()()()..)()&PP/R 8$:pVe=/ =!"# $%3...()()()..)() 0P/R 8$:pVe=/ =!"# $%3&&&&&&&&&)()() 0P/R 8$:pVe=/ =!"#$%tDText5vDeCheck23vDeCheck24$$If!vh5R5#vR#v:V d4 0)5R5/ / / / / 44 daf4p$$If!vh5R5#vR#v:V d40)5R5/ / / / / 44 daf4p -$$If!vh52 5 5 5 #v2 #v #v #v :V d40)52 5 5 5 / / / / / 44 daf4p$$If!vh5R5#vR#v:V d40)5R5/ / / / / 44 daf4p $$If!vh5R5#vR#v:V d40)5R5/ / / / / 44 daf4p vDText17vDText17$$If!vh5R5#vR#v:V d40)5R5/ / / / / 44 daf4p vDText19vDText19$$If!vh5R5#vR#v:V d40)5R5/ / / / / 44 daf4p -$$If!vh5~ 5 5 5h #v~ #v #v #vh :V d40)5~ 5 5 5h / / / / / 44 daf4p)$$If!vh5R5#vR#v:V d4 0),5R5/ / / / / 44 daf4p$$If!vh5j555#vj#v#v#v:V d4;0)5j555/ / / / / 44 daf4$$If!vh5R5#vR#v:V d40)5R5/ / / / / 44 daf4$$If!vh5R5#vR#v:V d40)5R5/ / / / / 44 daf4$$If!vh5R5#vR#v:V d40)5R5/ / / / / 44 daf4$$If!vh5@ 5 5$ 5 #v@ #v #v$ #v :V d4 (0),5@ 5 5$ 5 / / / / / 44 daf4p(tDeCheck1tDeCheck2tDeCheck2tDeCheck3tDeCheck4tDeCheck2tDeCheck5tDeCheck6tDeCheck7tDeCheck7tDeCheck8tDeCheck9vDeCheck10vDeCheck11vDeCheck12vDeCheck13vDeCheck15vDeCheck16vDeCheck17vDeCheck18vDeCheck19vDeCheck20vDeCheck21vDeCheck22tDeCheck6tDeCheck7tDeCheck7tDeCheck8tDeCheck9vDeCheck10vDeCheck11vDeCheck12E$$If!vh5@ 5 5$ 5 #v@ #v #v$ #v :V d4F0)5@ 5 5$ 5 / / / / / 44 daf4p(#$$If!vh5@ 5#v@ #v:V d4 0)5@ 5/ / / / / 44 daf4ptDeCheck6vDeCheck13vDeCheck14$$If!vh5@ 5#v@ #v:V d4k0)5@ 5/ / / / / 44 daf4p$$If!vh5)#v):V d40)5)/ /  44 daf4p $$If!vh5\ 5p55'5'#v\ #vp#v#v':V d4> 20)5\ 5p55'/ / / / / 44 daf4p2"$$If!vh5\ 5p55'5'#v\ #vp#v#v':V d40)5\ 5p55'/ / / / / 44 daf4$$If!vh5\ 5p55'5'#v\ #vp#v#v':V d40)5\ 5p55'/ / / / / 44 daf4$$If!vh5\ 5p55'5'#v\ #vp#v#v':V d4>0)5\ 5p55'/ / / / 44 daf4vDeCheck25vDeCheck26vDeCheck27vDeCheck28vDeCheck29vDeCheck30vDeCheck31&$$If!vh555#v#v#v:V d4 )++555/  / /  / / 44 daf4p~$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4 2)++5\ 5p555/ /  /  / / 44 daf4p2vDText56vDText60$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  /  / / / 44 daf4vDText57vDText61$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  /  / / / 44 daf4vDText58vDText62$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  /  / / / 44 daf4vDText59vDText63$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/ / / / / 44 daf4$$If!vh5)#v):V d4)5)/  / 44 daf4p J$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4 2)5\ 5p555/  / 44 daf4p2$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  /  / / / 44 daf4$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  /  / / / 44 daf4$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  /  / / / 44 daf4$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  /  / / / 44 daf4$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  /  / / / 44 daf4$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  /  / / / 44 daf4$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  /  / / / 44 daf4$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/ / / / / 44 daf4$$If!vh5)#v):V d4Z),5)/ / 44 daf4p J$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4 2)5\ 5p555/  / 44 daf4p2$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  / / / 44 daf4$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  / / / 44 daf4$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/  / / / 44 daf4$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/ / / / / 44 daf4$$If!vh5\ 5p555#v\ #vp#v#v#v:V d4)5\ 5p555/ / / / / 44 daf4$$If!vh555#v#v#v:V $555/ 44 pD@D Normal1$7$8$H$_HmH sH tH DA@D Default Paragraph FontVi@V  Table Normal :V 44 la (k(No List \O\ Level 1$1$7$8$H$^a$CJ_HaJmH sH tH 4@4 Header  !4 @4 Footer  !p$@"p Envelope Address!@ &+D/^@ CJOJQJ^JaJR%@2R Envelope Return1$7$8$H$ OJQJ^JHBH  Balloon TextCJOJQJ^JaJFV@QF nO@FollowedHyperlink >*B* phZobZ @Single Spacingd1$7$8$H$CJOJQJ^J6oar6 @ Attorney NameP$ PSf $6k6Lefj  ;P 2VW| ,-6?@Rdenwxy8h)PrGx!EF^w , U y    5 P Q p   v w A   %R_v-.123G[\_`au  !"#&'()*+./01236789:;>?@ABCFGHIJKNOPQRSVWXYZ[ 3_z (>\| RSQ(RUX[^ad;|4u8y./  )BHfk$9YegivH '!h!!!/"3"7"x"""" #(#)#A#Y#f#z###############$$$00000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 0 0000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000000 0 0 000000000 00000000000000000000000 0 0 00000000000000000000000000 000000 000 000 0 0 0 0 0 0 0 0 0 0 0 0 0{00J{00J@0@0{000J@0{00 @0@0{0 0 G04F0H0000>  ///2 s 0 ;Z"R$*-Y"+-./1246>?ADGR[_bh  B ,?dw!PvZZ!*2:BJRZ(,j-Y !#$%&'()*,035789:;<=@BCEFHIJKLMNOPQSTUVWXYZ\]^`acgiXs*0BNThtz,8Hhx)9P`r$GWx!1^nw  , < U e y Q a 0 = M s %+3?EGSYamsu$ FG$G$FFFFG$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$G$FFFFFFFF8  @: (  6   b   C "` B S  ? 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L^`LhH.FM@> z!,/        Ey        TVQO{'M 5 Y 3  a ~g:(b" 0 = "y".>3/!4(5k7%858gY9Z9:.=Ve=nO@ fAsBcDIG#WGUHyJ KwKxK^QtS BTAXFXXUZPm\]u_l>aRl=mLoXjq?r+\u:v?@v yxyo9{b{Fu|yp4qBJHxc)[kTQ:Oe0U#Rff4ekOen: mkEoB'V#;UW#5=5BUosKCxC6dg[q>ei @*$>Y ;P 2VW| ,-6?@RdenwxP  5 P Q p   v w %Rv-.123G[\_`au  !"#&'()*+./01236789:;>?@ABCFGHIJKNOPQRSVWXYZ[$@Adobe PDFNe03:winspoolAdobe PDF ConverterAdobe PDFdLetterPRIV ''''0\KhCFF0EBDAStandardAdobe PDFdLetterPRIV ''''0\KhCFF0EBDAStandard####|--$``@` `@```8@`$`L@`@UnknownGz Times New Roman5Symbol3& z ArialG5  hMS Mincho-3 fg5& zaTahoma?5 z Courier New"FFFPJ@PJ@!xxd##2qHP?y"District Court ClerkMichael Sommermeyer  Oh+'0 $ @ L X dpxDistrict Court ClerkNormalMichael Sommermeyer2Microsoft Word 10.0@@>[@ʤ/\@ʤ/\PJ՜.+,0 hp  Clark County@# District Court Title  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijkmnopqrstuvwxyz{|}~Root Entry FN\Data lI1TableVoWordDocumentSummaryInformation(DocumentSummaryInformation8CompObjj  FMicrosoft Word Document MSWordDocWord.Document.89q