The following portion of the Certificate of Death must be completed by the nearest relatives.  Please print this form and complete each box accurately and legibly.  Coroner or Doctor will complete and certify the cause of death.
      PLEASE SEND THIS PAGE BY FAX WHEN COMPLETED TO: 1 (323) 773-3345

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Decedent
Personal
Data

Name of Decedent - First (Given)                      Middle                                Last (Family)
Date of Birth                    Age                          Sex                             Date of Death                    Hour
                                   
State of Birth               Social Security No.                    Military Service         Marital Status        Education-Years Completed
Yes  No                      
Race                                                Hispanic - Specify                                          Usual Employer
        Yes  No         
Occupation                                                Kind of Business                                        Years in Occupation
   

Usual
Residence

Residence - (Street and Number or Location)
City                                       County                                    Zip Code                  Yrs in County      State or Foreign Country
    

Informant

Name, Relationship                                           Mailing Address (Street and Number, City or Town, State, Zip

Spouse
and
Parent
Info

Name of Surviving Spouse - First  Middle  Last (Maiden Name)
Name of Father - First          Middle                            Last                                                          Birth State
 
Name of Mother -First         Middle                            Last (Maiden)                                                                 Birth State
 

PLEASE COMPLETE THE FOLLOWING INFORMATION

I HEREBY DECLARE that I have the authority and hereby authorize RELEASE from place of death 
and CREMATION for (Name of Decedent):
_______________________________________________
under direction and services of the Cremation Society of Los Angeles - 1-(800) 615-5501

My Name (Printed) _________________________________________  Relationship:____________________

Address: ________________________________________________________________________________

City: ____________________________________ State: ________________________ Zip:_______________

My telephone: _______________________________ Other telephone: _______________________________

Note: ___________________________________________________________________________________

(   ) I will pay for services by credit card, and provide card number and expiration date by telephone.
(   ) I will receive cremated remains at your main office in Bell Gardens by appointment.
(   ) Please mail cremated remains by certified mail for an additional total fee of $45.00.
(   ) Please place cremated remains at sea and provide confirmation upon completion for a fee of $50.00.

If I fail to give specific instructions or call for the cremated remains within 45 days after cremation, I hereby authorize and hold harmless the Cremation Society of Los Angeles to place the cremated remains at sea and charge my credit card for services.

Signed:_________________________________________________________ Date:_____________________

Witness: _______________________________________________________ Date: _____________________