UCLA

UCLA Death Notice

UCLA Office of the Chancellor

AFFILIATION (check all that apply):

o Employee – Faculty

o Employee – Staff

o Student

o Medical Resident or Clinical Fellow

o Postdoctoral Fellow or Visiting Scholar

o 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:

o  Facilities Management, 51827

o  Office of Media Relations, 52585

o  Communications Technology Services, 51990

 The following offices will receive copies of this notice:

o  Chancellor’s Communications Service, 3148 Murphy Hall, 140501

o  Academic Senate (faculty), 3125 Murphy Hall, 140801

o  Campus Human Resources, Suite 200, 10920 Wilshire Blvd., 146548

o  Campus Benefits Programs Office, Suite 200, 10920 Wilshire Blvd., 146548

o  Emeriti Center, 1116 Rolfe Hall, 143702

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

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

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

o  Payroll, 10920 Wilshire Blvd., 6th Floor, 141648

o  Office of Media Relations, James West Center, 143107

Received by                                                                                  

Date/Time___________________________________________

Revised 4/3/2025

Office of Adm VC