Preview
. , , 1775 Concord Ave
Superior Court of California Chico CA 95928
County of Butte Civil
530-532-7009
BACKGROUND CHECK
Requested For Name Change Petition
To: Butte County Sheriff's Office
Fax: (530) 538-2099
From: Superior Court of California, County of Butte
1775 Concord Avenue
Chico, CA 95928
Phone: (530) 532-7009
Fax: (530) 532-7042
Date: January 19, 2018
Name: Charles Joseph Branish Date of Birth: July 07, 1955
Court Case #: 17CV03543
Court Date:
Subject: Request of the following background check pursuant code of Civil procedure § 1279.5(e): To
"determine whether or not the applicant isunder the jurisdiction of the Department of
Corrections or is required to register as a sex offender pursuant § 290 of the Penal code."
CLETS
Signature of person performing check
CJIS
Signature of person performing check
Please see attached petition with the name and information about the person requesting a name change.
D Nothing on file
Signature
E] See attached findings
Signature
NC-200
WATTORN‘EY (Name, sure Barnumber, and address): STATE BAR NO:
ATTORNEY OR PARTY
was: Charles Joseph Branish
Fm we '
smear mass: 4333 Pentz Road #10-A F Su erior Court -
f°f California
F
sma- Ca C OUFW 0 Butte
CW: Paradise ZJPoooe 95959. I
530-877-1796
TELEPHONE Nan. w No. : .
L
WWW ",3 .
E
JAN 08 2018
(Hm):
ATTORPEY FOR E
b y Iener, Clerk
SUPERIOR COURT OF CALIFORNIA, COUNTY OF Butte D
smear mess: 1775 Concord Ave
B? 08q
MAILING ADDRESS:
cmmazrpcooe- Chico, 95928
mums; Chico
PETITION OF (Name):
lNRE: Charles Joseph Branlsh
I
'
A W110 &\ CASE
'
PETITION FOR CHANGE OF NAME AND GENDER
_
»
i7~L \i 0'5 {H :77
Before on complete this tition, you should read the Instructions tor Filing a Petition tor Change of Name and Gender on the next
page. on must answer alquestions and check all boxes that app
to on on this petition. You must file this petition In the superior
court of the county where the person whose name Is to be change
rec doe.
1. Petitioner (present name):
Charles Joseph Branlsh is a resident of this county.
2. Petitioner requests that the court decree that petitioner‘s name is changed to (proposed name):
Ruby Kay Branlsh
3. Petitioner requests a decree that the petitioner's gender is changed:
a. [1—] from male-to female.
b. E] from female to male.
4. An affidavit or a declaration of a physlcian documenting the gender change through clinically appropriate treatment as provided
under Health and Safety Code sections 103425 and 103430 is attached to this petition. (Declaration of Physician (form NC-210)
may be used for this purpose.) .
I
5. Petitioner requests that the court order that a new birth certificate be issued reflecting the gender and name changes sought by
this petition.
6. Petitioner requests that the court issUe an order directing all interested persons to appear and show cause why the petition for
change of name should not be granted.
7..
Petitioner provides the following Information in support of this petition:
.
a. The information contained in the physician's affidavit or declaration.
b—t. The information contained In the‘attachment (attach a completed copy of the attachment
Name and Information About
the Person Whose Name Is to Be Changed (form NG-110)).
(lnaouclionaonnmmge) Pequot:
mmumm PE'ITITON FOR CHANGE OF NAME
nggmgggggg
My 1. 2014]
NC-ZOOlRav. AND GENDER www.menevv
\
INSTRUCTIONS FOR FILING A PETITION FOR CHANGE OF NAME AND GENDER
1. Where to File
The petition for change of name and gender must be filed in the superior court in the county where the petitioner presently lives.
2. Whose Name May Be Changed
The petition may be used to change one's name andrgender.
3. What Forms Are Required
You need an original and two copies of each of the following documents:
a. Petition for Change of Name and Gender (form NC-ZOO)
Name and Information About the Person Whose Name Is to Be Changed (Attachment to Petition) (form NC-110)
Declaration of Physician (form NC~210) (signed by the physician and attached to form NC-200)
SUP-.057
Order to Show Cause for Change of Name (form NC-220)
Decree Changing Name and Gender (form NC-230)
4. Filing and Filing Fee
Prepare an original Civil Case Cover Sheet
(form CM~010). File the original petition and Civil Case Cover Sheet with the clerk of
the court and obtain two filed-endorsed copies of the petition. A filing fee will be charged unless you qualify fora fee waiver.
(If
"
you want to apply for a fee waiver. see
Request to Waive Court Fees (form FW-001) and Information Sheet on Waiver of Court
Fees and Costs (form FW—OO1—INFO).)
5. Requesting a Court Hearing Date
You should request a date for the hearing on the Order to Show Cause at least six weeks in the future.
6. Filing the Order to Show Cause
After the hearing date has been included and you have obtained a judge‘s signature on the Order to Show Cause. file the original
order in the clerk's office and obtain filed-endorsed copies of the order.
7. Domestic Violence Confldentlallty Program
In cases where the petitioner is a participant in the state address confidentiality program (Safe at Home). the petition. the order to
show cause. and the decree should. instead ofgiving the proposed name.
indicate that the name is confidential
and on file with
‘
the Secretary of State. See Information Sheet for Name Change Proceedings
Under Address Confidentiality Program (Safe at
Home) (form NC-400-INFO).
8. Court Hearing
Bring copies of all documents to the hearing.
If thejudge grants the name and gender change petition. the judge will sign the
original decree.
9. Birth Certificate
To obtain a new birth certificate reflecting the change ofgender. file a certified copy of the order within 30 days with the Secretary
of State and the State Registrar and pay the applicable fees. You may write or contact the State Registrar at:
California Department of Public Health
Vital Records —- MS 5103
PO. Box 997410
Sacramento, CA 95899-7410
Phone: 916-445-2684
Website: www.cdph.ca.gov
Local courts may supplement these instructions.
Check with the court to determine whether supplemental information is available.
For instance. the court may provide you with additional written information identifying the department that handles name and
gender change petitions. and the times when petitions are heard.
~C~2°°IRev-Ju'v1-2°141
PETITION FOR CHANGE OF NAME New: ‘
AND'GENDER
NC-1 1 O
PETITION OF (Name of petitioner orpehiioners):
Charles Joseph Branish ,
CASE NUMBER.
,FORCHANGE OF NAME
‘
i7 LV 015‘q 3
'
NAME AND INFORMATION ABOUT THE PERSON
WHOSE NAME IS TO BE CHANGED Attachment 1 of 1
-
Attachment to Petition (form NC-100 or form NC-ZOO)
(You must use a separate attachment for each person whose name is to be changed. if petitioner is a guardian of a minor, a
supplemental attachment,Declaration of Guardian (form NC-i 106), must also be completed and attached for each minor whose name
is to be changed.)
7. (Continued) Petitioner applies for a decree to change the name of the following person:
b. E]
(1)
Self C] Other
Present name (specify): Charles Joseph Branlsh
(2) Proposed name (specify): Ruby Kay Branlsh
(3)
and presently I:
Born on (date of birth): 7/7/1955
under 18 years of age E] over 18 years of age
(4)
(5)
(6),
Born at (place of birth)
Sex (as stated on original birth certificate):
EC] Male I:
Philadelphia, Philadelphia County
PA
Female
Current residence address (street, city, county, and zip code):
4333 Pentz Road tho-A, Paradise, CA 95969
c. ReaSon for name change (explain): To better match gender Identity
:1.Relationship of the petitioner to the person whose name will be changed:
[E 1:]
(1)
(2)
(3)
I:
[:I
self
parent
guardian
'
(4)
(5) E
near relative(indicate relationship):
Other (specify):
e. If the person whose name will be changed is under 18 years of age, provide the names and addresses. if known, of the
following persons: g
V
(1) Father (name): ‘
(address):
'
(2) Mother (name): (address):
(3) (Only if neither parent is living) Near relatives (names, relationships,
and addresses):
f. If the person whose name will be changed is 18 years of age or older, that person must sign the following declaration:
DECLARATION
I
[:1
declare under penalty of perjury under the laws of the atate of Califomla that I am not
[:1
jurisdiction of the California Department of Corrections (in state prison or on parole) and
B
i am not
Iam
[:1
under the
I am
’
Drequired to register aos a sex offender under Penal Code section 290.
[-8
Charles Joseph Branlsh
(TYPEORPRNTNAM‘EOFPERSONWt-IOSE NAMEISTOBECHANGED)
’ Mg T%Z ELM
(SIGNATUREOF WNAMEISTOBE CHANGED)
.
(If petitioner ls represented by an attorney, the ettomey's signature follows):
.Date:
(TYPE OR PRINT NAME)
‘
’ A
(SIGNATURE OF ATTORNH)
(Each petitioner must sign this petition In the space provided below or. if additional pages are attached, at the end of the last
.
attachment) I declare under penalty of perjury under the laws of the State of California that the inforrnatlon in the foregoing petition is
true and conect.
Date: I-X— 30/3
fishes Joseph Branlsh. ~
.
(we on PRlNT NAME) (SIGMA or PElTnONER)
Date':
‘
meson PRINT NAME) (momma: cape-mouse)
:1 ADOADDlDNAL mm was roe mom. PETITIONERS E] SIGNATUREor PETITIONERS mums mar ATTAONENT
ForrnAdoptedfu'MmmUee
ween Card comm ATTACHMENT TO muwm 5 1275a we
mnemnmtzmq PETITION FOR CHANGE OF NAME
‘
NC-210/NC-310
_ PETITION OF (Name):. .
' .
.
‘CASE NUMBER:
BRANISH, Charles
o “s (A?)
-
1.
I 7 C\l
i
Page_ of_1__
1
DECLARATION OF PHYSICIAN
DOCUMENTING CHANGE OF GENDER THROUGH CLINICALLY APPROPRIATE TREATMENT
UNDER HEALTH AND SAFETY CODE SECTIONS 103425 AND 103430
Attachment to Petition for Change of Name and Gender (form NC- 200) or Petition for Change of Gender and Issuance of New Birth
Certificate (form NC- 300) .
.
‘
A
‘
To Whom It May Concern. j
I, Arthur Swislocki, MD, California license (342990, DEA AS9534264, am the physician of Charles I. .
Branish, with whom I have a doctor/patient relationship and whom I have treated. The appliCant and I
have a doctor/patient relationship which rs evident 1n having one or more clinical encounters between
doctor and patient. The patient has had appropriate clinical treatment for gender transition to the new
female gender. As such it is appropriate for her sex to be listed in the birthcertificate as female.
I declare under penalty of perjury under the laws of the United States that the foregoing Istrue and correct.
Thank you in advance for treating my patient with dignity and respect.
I declare under penalty of perjury under the laws of the State of Callfomia that the infonnation'In the foregoing declaration is true
and correct. .
Date: December 29, 201-7
Arthur Swrslocki MD
'
‘
(TYPE 0R PRINT NAME OF PHYSICIAN)
Form Approved tor Options! Use
Jumcmomm
’
DECLARATION OF PHYSICIAN—ATTACHMENT
), QM” W
(SIGNATURE OF PHYSICIAN)
To PETITION Hemandsmw
M
Page1of
1
Code 55106425103430
Nozromce101Rev.January1.2m,21 ~
(Change of Name and Gender/Change of Gender) wwivwm1gfi
‘“ Department Of Veterans Affaf:fi
VA Northern California Health Care System (VANCHCS)
OCT 13, 2017
Arthur Swislocki, M.D., Endocrine and Diabetes Clinic
Dept of Veterans Affairs, Northern California Health Care System
Sacramento Medical Center
10535 Hospital Way, lllE/SAC
Mather, CA 95655-1200
CHARLES J BRANISH
4333 PENTZ RD SP 10A
PARADISE, CALIFORNIA 95969
Dear CHARLES J BRANISH:
I have just reviewed your recent lab reSults:
Estradiol is stable. Testosterone has dropped, dramatically and'as expected, With
leuprolide. I look forward to our next visit.
If you have any questions, you can leave a message for me at 925—372-2070.
VSincer ,, A
.
L’l/‘v /<5¢L¢¢A_/QZ&_¢’€L—’
/es/ Arthur L. M. Swislocki, MD
Section Chief, Endocrinology
Patient Record Number 7201093
. .
Otatient Medication Details
BRANISH, CHARLES‘J' 195 48— 0433 '; -:* CHICO PAcI CASCADE TEAM-1 LVNJpl 07, 1955 (62)
*** wQRK CORY ONLY *** ~
.5 IPrinted;’NcVV27, 2017- 16 04
1:1: 1 MOUTHWASH, pleaSe COmplete a manual check for Drug
'/ Interactions -and Duplicate Therapy.
MEDICATION
Run Date.
.Include
HISTORY
NOV 27
for ocI’2S"
2017@16: 04
Clinic
2017
~higzl
to NOV.27;12017‘"7.
.: .4
Inpatient and Orders
~
‘
‘
Page: 1 ‘
MBDICATIONS SEARCH LIST: LEUPROLIDE (ELIGARD) (1 MQNTH)
Patient: BRANISH, CHARLES J Wyifv '
ssN: :3 19I 48— 0433 ~
'DOB:
JUL 7,1955 (62) V
__I ~. '; ‘~ 4,, 4*‘-
I
. .~' .
gT..M;;I‘
V
Sex. 5~
Ht/Wt:g ,‘~ia3qm/75.75kg
'.' ....L'
'
»
MALE 5‘ .Ward;
Rm: -
,
;
~ ‘
.~’:fi i? .,1'~, 1
’7 '~“7 i'1 V
I
‘4 I
:<.21j.;5fi
A
.
' ’4
Dx: V 1
'
Last Mvm i DEC 1172014@10;45 ' '
Type:
ADR5:.
.,
‘No ApRs 6n file, ".
AllergieSé,jPENICILLINr.I_1
Location'jW
UnitS3 ,,‘
6‘1
f
:2“.
Units
St
of
Sch Administration
~
Date
,. iy
"_,
Y
4‘3
3"
;
iBody.site
.
4 ‘4
‘
.. 'Iu. '
"Medication”&.Dosage
.
GIVEN .:~ Administration “ '*- ~ ~
I j
<<<< NO HISTORY FOUND FOR THIS TIME FRAME >>>>
BRANISH,CHARLES‘J‘ 4' 4"1‘ >f‘
‘j 1“.'I ”I7
.
195—4840433
Ward:,..RocmrBee:
End of report
Outpatient Medication Details
BRANISH,CHARLES J ~195e48-0433.= CHICO PACT CASCADE TEAM 1 LVNJu1D07, 1955 (62)'
*** WORK COPY ONLY *** ’- ‘
-
Printed: NOV 27, 2017’ 16:04
LEUPROLIDE (ELIGARD) (1 MONTH) INJ, susp, LA 7. 5MG
INJECT 1 SYRINGEFUL (7 5M6) UNDER THE SKIN Q MONTH a FOR PROSTATE.
Quantity: 1 Refills: 5,
Activity: V
,
'
_“4'; rf 1"}~'1, '
10/26/2017 10: 34 New Order (Renewal) entered by SWISLOCKI ARTHUR L M (PHYSICIAN)
Order Text; .~
LEUPROLIDE (ELIGARD) (1 MONTH) INJ, SUSP, LA 7. 5MG '
.~
INJECT L SYRINGEFUL (7. 5M6) UNDER THE SKIN Q MONTH - FOR
PROSTATE, .1
" '“ ’Quantity: Refills: 5‘
"
'
.1
Nature Of Order: VELECTRONTCALLY ENTERED 1
ETeC Signature:’ HSWISLOCKI, ARTHUR L M (PHYSICIAN) on T0/26/2017 10: 42
Current‘Data:
.
Treating Specialty: " ,
~; ~ ‘
Ordering Locationzfl .‘ 'SAC ENDOCRINE SWISLOCKI
IstartzDate/Timez.‘ .’r,. .
‘11/14/2017 (originally 05/25/2017)
Stop Date/Time_: '1 f10/2_7/2018
Curr.ent Status: ‘ V ‘
ACTIVE
Jorders that are active or have been accepted by the service for
'processing. ‘e. g. , Diefietic orders are active upon being
ordered, Pharmacy orders are active .When the order is Verified,
Lab orders are active when the Sample has been collected,
Radiology orders are active upOn. registration.
'
a
Order #51080991
Orderz; ”.'fl .1 H, '6_“1gvfi~ . ,.. .
;.1 : _u ”.1 UK W 7'
"
.
Medication: ‘ ~
‘
-
LEUPROLIDE (ELIGARD) (1 MONTH) INJ, SUSP, LA 7. 5MG-
'Instructions:~” * .
.‘ ~1>SYRINGEFUL (7. 5MG) 7. SMG S_UBCUTANEOUS Q MONTH
Sig:
INJECT l SYRINGEFUL
7
V
v
;-,
(7. SMG) UNDER THE SKIN Q MONTH
Patient Instructions. ‘
‘
. .
—
FOR PROSTATE.
Quantity:
‘
~
'1 5. ., .’;
4' . . .
Refills: ‘
'
~
‘5 T'a‘ A3
~_
Pick Up: . ,V ..MA1L~'A -
. s ~;
Priority: j ~
-
-ROUTINE7
Comments:
Dispense Drugs (units/dose):j LEUPROLIDE.(ELIGARD)7(5MG(12MONTH)LA INJ ().3
. Last Filledé ._
“
.
‘11/14/17
. Refills Remaining: ' ' '
5
Filled:
~" ' H
'
'1
;,;" 11/14/17 (Mail) ,
‘
~
RENEWED FROM RX # 25190980
.Prescription#: '
.~ '
25190980A ‘
~
Pharmacist: _g. WATTS, PAUL
.First Party Pay Exemptions .
' "
For conditions related to; SERVICE CONNECTED CONDITION
Order Checks:
LOW: Order Checks could not be done for Drug: ALOH/DIPH/MAG/LIDO/SIMET
____‘__._-____.__._____—__.......__...._...__-_-_...___.__....—._____-_________p.__—..—..,-...—........._....
Order Details - 49994228
BRANISH,CHARLES J 195-48—0433 Jul 07, 1955 (62)
*f* WORK COPY ONLY *** .
Printed: Nov 27, 2017 16:08
First Party Pay Exemptions
For conditions related to: SERVICE CONNECTED CONDITION
Order Checksz,
LOW:~. Order Checks could not be done for Drug: ALOH/DIPH/MAG/LIDO/SIMET
1:1:1 MOUTHWASHL please complete a manual check for Drug
Interactions and Duplicate Therapy. ‘
~
MEDICATION HISTORY for OCT 28, 2017 to NOV 27, 2017
Run Date: NOV 27, 2017@l6:08 ,,
Include Inpatient and Clinic Orders
Page: 1 -
MEDICATIONS SEARCH LIST: FINASTERIDE
Patient: BRANISH,CHARLES J ‘ SSN: 195-48-0433 DOB:
JUL 7,1955 (62)
‘
'
‘
’
Sex: MALE Ht/Wt: 183cm/75.75kg Ward:
’
Rm: ’
3
.
Dx: ‘ ~
, »
Last Mvmt: DEC 11,2014@10:45 Type:
'DISCHARGE ~
:
ADRs: No ADRs on file.
Allergies: PENICILLIN
Location. ‘
St Sch Administration Date By Body Site
Units Units ofv ,
‘
Medication & Dosage
GIVEN Adminis tration
<<<< NO HISTORY FOUND FOR THIS TIME FRAME >>>>
BRANISH,CHARLES J 195—48—0433
Ward: RoomeBed: ,
End of report
Order Details —
49994228
BRANISH,CHARLES J l95-48~O433 'Jul 07, 1955 (62).
*** WORK COPY ONLY *** Printed: Nov 27, 2017 16:08
FINASTERIDE TAB 5MG
TAKE ONE TABLET BY MOUTH ONCE DAILY BEFORE A MEAL - FOR PROSTATE.
Quantity: 30 Refills: 5
Activity:
07/19/2017 15:25 New Order (Renewal) entered by LAPATING, SUSAN (PHARMACY_ TECHNI)
Order.Text: FINASTERIDE TAB 5MG
TAKE ONE TABLET BY MOUTH ONCE DAILY BEFORE A MEAL - FOR
PROSTATE.
‘Quantity: 30 Refills: 5
Nature of Order: ELECTRONICALLY ENTERED
Elec Signature: SWISLOCKI,ARTHUR L M (PHYSICIAN) on 07/19/2017 15:36
Current Data:
Treating Specialty:
Ordering Location: PHARMACY CHICO OUTPT MED ED
Start Date/Time: 08/05/2017 (originally 02/16/2017)
Stop Date/Time: 07/20/2018
Current Status: ACTIVE
Orders that are active or have been accepted by the service for
processing. e. g. , Dietetic orders are active upon being
ordered, Pharmacy Orders are active when the order is verified,
Lab orders are active when the sample has been collected,
Radiology orders are active upon registration.
Order #49994228
Order:
Medication: FINASTERIDE TAB 5MG
Instructions: 5MG ORAL QDAILY AC
Sig:
TAKE ONE TABLET BY MOUTH ONCE DAILY BEFORE A MEAL
Patient InStructions:
—
FOR PROSTATE.
Days Supply: 30
Quantity: '30‘
Refills: 5 .
Pick Up: MAIL
Preview
. , , 1775 Concord Ave Superior Court of California Chico CA 95928 County of Butte Civil 530-532-7009 BACKGROUND CHECK Requested For Name Change Petition To: Butte County Sheriff's Office Fax: (530) 538-2099 From: Superior Court of California, County of Butte 1775 Concord Avenue Chico, CA 95928 Phone: (530) 532-7009 Fax: (530) 532-7042 Date: January 19, 2018 Name: Charles Joseph Branish Date of Birth: July 07, 1955 Court Case #: 17CV03543 Court Date: Subject: Request of the following background check pursuant code of Civil procedure § 1279.5(e): To "determine whether or not the applicant isunder the jurisdiction of the Department of Corrections or is required to register as a sex offender pursuant § 290 of the Penal code." CLETS Signature of person performing check CJIS Signature of person performing check Please see attached petition with the name and information about the person requesting a name change. D Nothing on file Signature E] See attached findings Signature NC-200 WATTORN‘EY (Name, sure Barnumber, and address): STATE BAR NO: ATTORNEY OR PARTY was: Charles Joseph Branish Fm we ' smear mass: 4333 Pentz Road #10-A F Su erior Court - f°f California F sma- Ca C OUFW 0 Butte CW: Paradise ZJPoooe 95959. I 530-877-1796 TELEPHONE Nan. w No. : . L WWW ",3 . E JAN 08 2018 (Hm): ATTORPEY FOR E b y Iener, Clerk SUPERIOR COURT OF CALIFORNIA, COUNTY OF Butte D smear mess: 1775 Concord Ave B? 08q MAILING ADDRESS: cmmazrpcooe- Chico, 95928 mums; Chico PETITION OF (Name): lNRE: Charles Joseph Branlsh I ' A W110 &\ CASE ' PETITION FOR CHANGE OF NAME AND GENDER _ » i7~L \i 0'5 {H :77 Before on complete this tition, you should read the Instructions tor Filing a Petition tor Change of Name and Gender on the next page. on must answer alquestions and check all boxes that app to on on this petition. You must file this petition In the superior court of the county where the person whose name Is to be change rec doe. 1. Petitioner (present name): Charles Joseph Branlsh is a resident of this county. 2. Petitioner requests that the court decree that petitioner‘s name is changed to (proposed name): Ruby Kay Branlsh 3. Petitioner requests a decree that the petitioner's gender is changed: a. [1—] from male-to female. b. E] from female to male. 4. An affidavit or a declaration of a physlcian documenting the gender change through clinically appropriate treatment as provided under Health and Safety Code sections 103425 and 103430 is attached to this petition. (Declaration of Physician (form NC-210) may be used for this purpose.) . I 5. Petitioner requests that the court order that a new birth certificate be issued reflecting the gender and name changes sought by this petition. 6. Petitioner requests that the court issUe an order directing all interested persons to appear and show cause why the petition for change of name should not be granted. 7.. Petitioner provides the following Information in support of this petition: . a. The information contained in the physician's affidavit or declaration. b—t. The information contained In the‘attachment (attach a completed copy of the attachment Name and Information About the Person Whose Name Is to Be Changed (form NG-110)). (lnaouclionaonnmmge) Pequot: mmumm PE'ITITON FOR CHANGE OF NAME nggmgggggg My 1. 2014] NC-ZOOlRav. AND GENDER www.menevv \ INSTRUCTIONS FOR FILING A PETITION FOR CHANGE OF NAME AND GENDER 1. Where to File The petition for change of name and gender must be filed in the superior court in the county where the petitioner presently lives. 2. Whose Name May Be Changed The petition may be used to change one's name andrgender. 3. What Forms Are Required You need an original and two copies of each of the following documents: a. Petition for Change of Name and Gender (form NC-ZOO) Name and Information About the Person Whose Name Is to Be Changed (Attachment to Petition) (form NC-110) Declaration of Physician (form NC~210) (signed by the physician and attached to form NC-200) SUP-.057 Order to Show Cause for Change of Name (form NC-220) Decree Changing Name and Gender (form NC-230) 4. Filing and Filing Fee Prepare an original Civil Case Cover Sheet (form CM~010). File the original petition and Civil Case Cover Sheet with the clerk of the court and obtain two filed-endorsed copies of the petition. A filing fee will be charged unless you qualify fora fee waiver. (If " you want to apply for a fee waiver. see Request to Waive Court Fees (form FW-001) and Information Sheet on Waiver of Court Fees and Costs (form FW—OO1—INFO).) 5. Requesting a Court Hearing Date You should request a date for the hearing on the Order to Show Cause at least six weeks in the future. 6. Filing the Order to Show Cause After the hearing date has been included and you have obtained a judge‘s signature on the Order to Show Cause. file the original order in the clerk's office and obtain filed-endorsed copies of the order. 7. Domestic Violence Confldentlallty Program In cases where the petitioner is a participant in the state address confidentiality program (Safe at Home). the petition. the order to show cause. and the decree should. instead ofgiving the proposed name. indicate that the name is confidential and on file with ‘ the Secretary of State. See Information Sheet for Name Change Proceedings Under Address Confidentiality Program (Safe at Home) (form NC-400-INFO). 8. Court Hearing Bring copies of all documents to the hearing. If thejudge grants the name and gender change petition. the judge will sign the original decree. 9. Birth Certificate To obtain a new birth certificate reflecting the change ofgender. file a certified copy of the order within 30 days with the Secretary of State and the State Registrar and pay the applicable fees. You may write or contact the State Registrar at: California Department of Public Health Vital Records —- MS 5103 PO. Box 997410 Sacramento, CA 95899-7410 Phone: 916-445-2684 Website: www.cdph.ca.gov Local courts may supplement these instructions. Check with the court to determine whether supplemental information is available. For instance. the court may provide you with additional written information identifying the department that handles name and gender change petitions. and the times when petitions are heard. ~C~2°°IRev-Ju'v1-2°141 PETITION FOR CHANGE OF NAME New: ‘ AND'GENDER NC-1 1 O PETITION OF (Name of petitioner orpehiioners): Charles Joseph Branish , CASE NUMBER. ,FORCHANGE OF NAME ‘ i7 LV 015‘q 3 ' NAME AND INFORMATION ABOUT THE PERSON WHOSE NAME IS TO BE CHANGED Attachment 1 of 1 - Attachment to Petition (form NC-100 or form NC-ZOO) (You must use a separate attachment for each person whose name is to be changed. if petitioner is a guardian of a minor, a supplemental attachment,Declaration of Guardian (form NC-i 106), must also be completed and attached for each minor whose name is to be changed.) 7. (Continued) Petitioner applies for a decree to change the name of the following person: b. E] (1) Self C] Other Present name (specify): Charles Joseph Branlsh (2) Proposed name (specify): Ruby Kay Branlsh (3) and presently I: Born on (date of birth): 7/7/1955 under 18 years of age E] over 18 years of age (4) (5) (6), Born at (place of birth) Sex (as stated on original birth certificate): EC] Male I: Philadelphia, Philadelphia County PA Female Current residence address (street, city, county, and zip code): 4333 Pentz Road tho-A, Paradise, CA 95969 c. ReaSon for name change (explain): To better match gender Identity :1.Relationship of the petitioner to the person whose name will be changed: [E 1:] (1) (2) (3) I: [:I self parent guardian ' (4) (5) E near relative(indicate relationship): Other (specify): e. If the person whose name will be changed is under 18 years of age, provide the names and addresses. if known, of the following persons: g V (1) Father (name): ‘ (address): ' (2) Mother (name): (address): (3) (Only if neither parent is living) Near relatives (names, relationships, and addresses): f. If the person whose name will be changed is 18 years of age or older, that person must sign the following declaration: DECLARATION I [:1 declare under penalty of perjury under the laws of the atate of Califomla that I am not [:1 jurisdiction of the California Department of Corrections (in state prison or on parole) and B i am not Iam [:1 under the I am ’ Drequired to register aos a sex offender under Penal Code section 290. [-8 Charles Joseph Branlsh (TYPEORPRNTNAM‘EOFPERSONWt-IOSE NAMEISTOBECHANGED) ’ Mg T%Z ELM (SIGNATUREOF WNAMEISTOBE CHANGED) . (If petitioner ls represented by an attorney, the ettomey's signature follows): .Date: (TYPE OR PRINT NAME) ‘ ’ A (SIGNATURE OF ATTORNH) (Each petitioner must sign this petition In the space provided below or. if additional pages are attached, at the end of the last . attachment) I declare under penalty of perjury under the laws of the State of California that the inforrnatlon in the foregoing petition is true and conect. Date: I-X— 30/3 fishes Joseph Branlsh. ~ . (we on PRlNT NAME) (SIGMA or PElTnONER) Date': ‘ meson PRINT NAME) (momma: cape-mouse) :1 ADOADDlDNAL mm was roe mom. PETITIONERS E] SIGNATUREor PETITIONERS mums mar ATTAONENT ForrnAdoptedfu'MmmUee ween Card comm ATTACHMENT TO muwm 5 1275a we mnemnmtzmq PETITION FOR CHANGE OF NAME ‘ NC-210/NC-310 _ PETITION OF (Name):. . ' . . ‘CASE NUMBER: BRANISH, Charles o “s (A?) - 1. I 7 C\l i Page_ of_1__ 1 DECLARATION OF PHYSICIAN DOCUMENTING CHANGE OF GENDER THROUGH CLINICALLY APPROPRIATE TREATMENT UNDER HEALTH AND SAFETY CODE SECTIONS 103425 AND 103430 Attachment to Petition for Change of Name and Gender (form NC- 200) or Petition for Change of Gender and Issuance of New Birth Certificate (form NC- 300) . . ‘ A ‘ To Whom It May Concern. j I, Arthur Swislocki, MD, California license (342990, DEA AS9534264, am the physician of Charles I. . Branish, with whom I have a doctor/patient relationship and whom I have treated. The appliCant and I have a doctor/patient relationship which rs evident 1n having one or more clinical encounters between doctor and patient. The patient has had appropriate clinical treatment for gender transition to the new female gender. As such it is appropriate for her sex to be listed in the birthcertificate as female. I declare under penalty of perjury under the laws of the United States that the foregoing Istrue and correct. Thank you in advance for treating my patient with dignity and respect. I declare under penalty of perjury under the laws of the State of Callfomia that the infonnation'In the foregoing declaration is true and correct. . Date: December 29, 201-7 Arthur Swrslocki MD ' ‘ (TYPE 0R PRINT NAME OF PHYSICIAN) Form Approved tor Options! Use Jumcmomm ’ DECLARATION OF PHYSICIAN—ATTACHMENT ), QM” W (SIGNATURE OF PHYSICIAN) To PETITION Hemandsmw M Page1of 1 Code 55106425103430 Nozromce101Rev.January1.2m,21 ~ (Change of Name and Gender/Change of Gender) wwivwm1gfi ‘“ Department Of Veterans Affaf:fi VA Northern California Health Care System (VANCHCS) OCT 13, 2017 Arthur Swislocki, M.D., Endocrine and Diabetes Clinic Dept of Veterans Affairs, Northern California Health Care System Sacramento Medical Center 10535 Hospital Way, lllE/SAC Mather, CA 95655-1200 CHARLES J BRANISH 4333 PENTZ RD SP 10A PARADISE, CALIFORNIA 95969 Dear CHARLES J BRANISH: I have just reviewed your recent lab reSults: Estradiol is stable. Testosterone has dropped, dramatically and'as expected, With leuprolide. I look forward to our next visit. If you have any questions, you can leave a message for me at 925—372-2070. VSincer ,, A . L’l/‘v /<5¢L¢¢A_/QZ&_¢’€L—’ /es/ Arthur L. M. Swislocki, MD Section Chief, Endocrinology Patient Record Number 7201093 . . Otatient Medication Details BRANISH, CHARLES‘J' 195 48— 0433 '; -:* CHICO PAcI CASCADE TEAM-1 LVNJpl 07, 1955 (62) *** wQRK CORY ONLY *** ~ .5 IPrinted;’NcVV27, 2017- 16 04 1:1: 1 MOUTHWASH, pleaSe COmplete a manual check for Drug '/ Interactions -and Duplicate Therapy. MEDICATION Run Date. .Include HISTORY NOV 27 for ocI’2S" 2017@16: 04 Clinic 2017 ~higzl to NOV.27;12017‘"7. .: .4 Inpatient and Orders ~ ‘ ‘ Page: 1 ‘ MBDICATIONS SEARCH LIST: LEUPROLIDE (ELIGARD) (1 MQNTH) Patient: BRANISH, CHARLES J Wyifv ' ssN: :3 19I 48— 0433 ~ 'DOB: JUL 7,1955 (62) V __I ~. '; ‘~ 4,, 4*‘- I . .~' . gT..M;;I‘ V Sex. 5~ Ht/Wt:g ,‘~ia3qm/75.75kg '.' ....L' ' » MALE 5‘ .Ward; Rm: - , ; ~ ‘ .~’:fi i? .,1'~, 1 ’7 '~“7 i'1 V I ‘4 I :<.21j.;5fi A . ' ’4 Dx: V 1 ' Last Mvm i DEC 1172014@10;45 ' ' Type: ADR5:. ., ‘No ApRs 6n file, ". AllergieSé,jPENICILLINr.I_1 Location'jW UnitS3 ,,‘ 6‘1 f :2“. Units St of Sch Administration ~ Date ,. iy "_, Y 4‘3 3" ; iBody.site . 4 ‘4 ‘ .. 'Iu. ' "Medication”&.Dosage . GIVEN .:~ Administration “ '*- ~ ~ I j <<<< NO HISTORY FOUND FOR THIS TIME FRAME >>>> BRANISH,CHARLES‘J‘ 4' 4"1‘ >f‘ ‘j 1“.'I ”I7 . 195—4840433 Ward:,..RocmrBee: End of report Outpatient Medication Details BRANISH,CHARLES J ~195e48-0433.= CHICO PACT CASCADE TEAM 1 LVNJu1D07, 1955 (62)' *** WORK COPY ONLY *** ’- ‘ - Printed: NOV 27, 2017’ 16:04 LEUPROLIDE (ELIGARD) (1 MONTH) INJ, susp, LA 7. 5MG INJECT 1 SYRINGEFUL (7 5M6) UNDER THE SKIN Q MONTH a FOR PROSTATE. Quantity: 1 Refills: 5, Activity: V , ' _“4'; rf 1"}~'1, ' 10/26/2017 10: 34 New Order (Renewal) entered by SWISLOCKI ARTHUR L M (PHYSICIAN) Order Text; .~ LEUPROLIDE (ELIGARD) (1 MONTH) INJ, SUSP, LA 7. 5MG ' .~ INJECT L SYRINGEFUL (7. 5M6) UNDER THE SKIN Q MONTH - FOR PROSTATE, .1 " '“ ’Quantity: Refills: 5‘ " ' .1 Nature Of Order: VELECTRONTCALLY ENTERED 1 ETeC Signature:’ HSWISLOCKI, ARTHUR L M (PHYSICIAN) on T0/26/2017 10: 42 Current‘Data: . Treating Specialty: " , ~; ~ ‘ Ordering Locationzfl .‘ 'SAC ENDOCRINE SWISLOCKI IstartzDate/Timez.‘ .’r,. . ‘11/14/2017 (originally 05/25/2017) Stop Date/Time_: '1 f10/2_7/2018 Curr.ent Status: ‘ V ‘ ACTIVE Jorders that are active or have been accepted by the service for 'processing. ‘e. g. , Diefietic orders are active upon being ordered, Pharmacy orders are active .When the order is Verified, Lab orders are active when the Sample has been collected, Radiology orders are active upOn. registration. ' a Order #51080991 Orderz; ”.'fl .1 H, '6_“1gvfi~ . ,.. . ;.1 : _u ”.1 UK W 7' " . Medication: ‘ ~ ‘ - LEUPROLIDE (ELIGARD) (1 MONTH) INJ, SUSP, LA 7. 5MG- 'Instructions:~” * . .‘ ~1>SYRINGEFUL (7. 5MG) 7. SMG S_UBCUTANEOUS Q MONTH Sig: INJECT l SYRINGEFUL 7 V v ;-, (7. SMG) UNDER THE SKIN Q MONTH Patient Instructions. ‘ ‘ . . — FOR PROSTATE. Quantity: ‘ ~ '1 5. ., .’; 4' . . . Refills: ‘ ' ~ ‘5 T'a‘ A3 ~_ Pick Up: . ,V ..MA1L~'A - . s ~; Priority: j ~ - -ROUTINE7 Comments: Dispense Drugs (units/dose):j LEUPROLIDE.(ELIGARD)7(5MG(12MONTH)LA INJ ().3 . Last Filledé ._ “ . ‘11/14/17 . Refills Remaining: ' ' ' 5 Filled: ~" ' H ' '1 ;,;" 11/14/17 (Mail) , ‘ ~ RENEWED FROM RX # 25190980 .Prescription#: ' .~ ' 25190980A ‘ ~ Pharmacist: _g. WATTS, PAUL .First Party Pay Exemptions . ' " For conditions related to; SERVICE CONNECTED CONDITION Order Checks: LOW: Order Checks could not be done for Drug: ALOH/DIPH/MAG/LIDO/SIMET ____‘__._-____.__._____—__.......__...._...__-_-_...___.__....—._____-_________p.__—..—..,-...—........._.... Order Details - 49994228 BRANISH,CHARLES J 195-48—0433 Jul 07, 1955 (62) *f* WORK COPY ONLY *** . Printed: Nov 27, 2017 16:08 First Party Pay Exemptions For conditions related to: SERVICE CONNECTED CONDITION Order Checksz, LOW:~. Order Checks could not be done for Drug: ALOH/DIPH/MAG/LIDO/SIMET 1:1:1 MOUTHWASHL please complete a manual check for Drug Interactions and Duplicate Therapy. ‘ ~ MEDICATION HISTORY for OCT 28, 2017 to NOV 27, 2017 Run Date: NOV 27, 2017@l6:08 ,, Include Inpatient and Clinic Orders Page: 1 - MEDICATIONS SEARCH LIST: FINASTERIDE Patient: BRANISH,CHARLES J ‘ SSN: 195-48-0433 DOB: JUL 7,1955 (62) ‘ ' ‘ ’ Sex: MALE Ht/Wt: 183cm/75.75kg Ward: ’ Rm: ’ 3 . Dx: ‘ ~ , » Last Mvmt: DEC 11,2014@10:45 Type: 'DISCHARGE ~ : ADRs: No ADRs on file. Allergies: PENICILLIN Location. ‘ St Sch Administration Date By Body Site Units Units ofv , ‘ Medication & Dosage GIVEN Adminis tration <<<< NO HISTORY FOUND FOR THIS TIME FRAME >>>> BRANISH,CHARLES J 195—48—0433 Ward: RoomeBed: , End of report Order Details — 49994228 BRANISH,CHARLES J l95-48~O433 'Jul 07, 1955 (62). *** WORK COPY ONLY *** Printed: Nov 27, 2017 16:08 FINASTERIDE TAB 5MG TAKE ONE TABLET BY MOUTH ONCE DAILY BEFORE A MEAL - FOR PROSTATE. Quantity: 30 Refills: 5 Activity: 07/19/2017 15:25 New Order (Renewal) entered by LAPATING, SUSAN (PHARMACY_ TECHNI) Order.Text: FINASTERIDE TAB 5MG TAKE ONE TABLET BY MOUTH ONCE DAILY BEFORE A MEAL - FOR PROSTATE. ‘Quantity: 30 Refills: 5 Nature of Order: ELECTRONICALLY ENTERED Elec Signature: SWISLOCKI,ARTHUR L M (PHYSICIAN) on 07/19/2017 15:36 Current Data: Treating Specialty: Ordering Location: PHARMACY CHICO OUTPT MED ED Start Date/Time: 08/05/2017 (originally 02/16/2017) Stop Date/Time: 07/20/2018 Current Status: ACTIVE Orders that are active or have been accepted by the service for processing. e. g. , Dietetic orders are active upon being ordered, Pharmacy Orders are active when the order is verified, Lab orders are active when the sample has been collected, Radiology orders are active upon registration. Order #49994228 Order: Medication: FINASTERIDE TAB 5MG Instructions: 5MG ORAL QDAILY AC Sig: TAKE ONE TABLET BY MOUTH ONCE DAILY BEFORE A MEAL Patient InStructions: — FOR PROSTATE. Days Supply: 30 Quantity: '30‘ Refills: 5 . Pick Up: MAIL