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UCLA Procedure 160.0 : Attachment A

UCLA Death Notice

 (to be completed by the Office of the Chancellor)

UCLA Office of the Chancellor
  AFFILIATION (check all that apply):
      ___ Employee – Faculty
      ___ Employee – Staff
      ___ Student
      ___ Medical Resident or Clinical Fellow
      ___ Postdoctoral Fellow or Visiting Scholar
      ___ Emeritus/Emerita 
Name of Deceased Sex (M/F) Age
Department Title
Date of Death Time of Death (if known)
Cause of Death (if known)
Date Employment Began at UCLA Date Retired
Name of Surviving Spouse, Next of Kin, or Close Personal Friend
Address of Surviving Spouse, Next of Kin, or Close Personal Friend
Dependent (if other than Surviving Spouse or Next of Kin)
Address (if other than above)
Reported by

 Department/Extension
The Flag will be at half-mast on:
 Chancellor’s Office letter of condolence will be sent on:

 

The following offices have been notified by telephone or e-mail:

___ Facilities Management, 51827

___ Office of Media Relations, 52585

 
___ Communications Technology Services, 51990

The following offices will receive copies of this notice:

___Chancellor’s Communications Service,
      3148 Murphy Hall, 140501

___Academic Senate (faculty),
      3125 Murphy Hall, 140801

___Campus Human Resources,
      Suite 200, 10920 Wilshire Blvd., 146548

___Campus Benefits Programs Office,
      Suite 200, 10920 Wilshire Blvd., 146548

___List Maintenance Manager, Mail & Document Services,
      CSB #2, 136108

___Emeriti Center,
      1116 Rolfe Hall, 143702


 
___Dean of Students Office (all students),
      1206 Murphy Hall, 141501

___Dean’s Office, Graduate Division
      (graduate students, postdoctoral fellows, and visiting scholars),
      12-138 CHS, 172216

___Dean’s Office, School of Medicine
      (medical resident or clinical fellow),
      12-138 CHS, 172216

___Payroll,
      10920 Wilshire Blvd., 6th Floor, 141648

___Office of Media Relations,
      James West Center, 143107
_____________________________________________
Received by		   _____________________________________________
Date/Time

Revised 5/1999