The Cremation Society of Los Angeles      FAX # (323) 773-3345              

                   Death Certificate Information Form

(Statistical information required by the State of California to prepare a State Certificate of Death and is kept strictly confidential)

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First Name:Middle:Last:

Legal Residence Address:
City:County:State 
Zip:Phone Number:         Male Female 
Years in county:Highest school grade completed:
Married     Never Married     Divorced    Widowed
Birthplace (State or Foreign Country):   Birth date:
Social Security Number:     Race:
Occupation (Present): Or Before Retirement:
Number of years:   Kind of Business:
Employer (Present): Or Before Retirement:
United States Veteran Yes  No (Please fax copy of military discharge papers)
SPOUSE (First, Middle, Maiden Name)
Mothers Name (First, Middle, Maiden Name)
Birthplace (State or Country)
Fathers Name (First, Middle, Last)
Birthplace (State of Country)
Person in Charge of Financial Arrangements:
Relationship:Phone Number:
Address, City, State, Zip
Alternate Person to be notified:
Relationship: Phone Number:
Address, City, State, Zip