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

License # FD 1694
Death Certificate Information Form

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

Name First_______________________ Middle_______________________ Last __________________________

Legal Residence Address ________________________________________ City __________________________

County ____________________________ Zip__________________ Phone Number_______________________

[  ] Male          [  ] Female     Number of years in county ______    Number of highest school grade completed ______

[  ] Married                   [  ] Never Married                     [  ] Divorced                            [  ] Widowed

United States Veteran:  [  ] Yes      [  ] No               (Please include a copy of military discharge papers)

Birthplace (State or Foreign Country) ________________________________ Birth Date ___________________

Social Security Number _______________________________________ Race __________________________

Occupation (Present or Before Retirement) ____________________________________ Number of Years ________

Employer (Present or Before Retirement) ___________________________________________________________

Kind of Business __________________________________________________________________________

Fathers Name
 (First, Middle, Last)________________________________________________ Birth Place ___________________

Mothers Name
(First, Middle, Maiden Name) ________________________________________ Birth Place ___________________

Spouse:  
First Name ______________________ Middle _____________________ (Maiden Name)_____________________

Name of Person in Charge of Final Arrangements __________________________________________________

Relationship ___________________________________ Phone Number _______________________________

Address _______________________________________ City, State Zip ______________________________

Signature_________________________________________________________________________________