Print this form, fill in the death certificate information and fax it to
Cremation Society of Los Angeles 
(Lic. # FD 1694)               FAX # (323) 773-3345   
(All questions must be answered.  If you do not know the answer, simply write Unknown in the space)

1.Name of the Deceased:

First Name: _________________   Middle: ___________________  Last: _____________________

2.Did the Deceased go by any other name?
AKA (Also Know As) - If yes, include full name - If no, leave blank __________________________________

3.Deceased's date of birth: ______________       Age: _______       Sex: _________

4.State or Foreign Country of Birth: ____________________________________________________

5.Social Security Number of the Deceased: ____________________________________

6.Was the Deceased Ever in the U.S. Armed Forces? _______________

7.What is the Deceased's marital status? (  )Married  (  )Widowed  (  )Divorced  (  )Never Married 

8.What is the highest level/degree of education obtained by the Deceased? _____________________
                                                                                                                                                (High school, AA, BA, PhD)
9.What is the Deceased's race? You may enter up to three races.

_________________________   _________________________   ________________________

10.If Race is other, please specify: _____________________________________________________

11. If Race is American Indian, please specify Tribe (s): ___________________________________

12.What was the Deceased's usual occupation?
The type of work done for most of his/her life. Do not use RETIRED. ____________________________________

13.What kind of business or industry did the Deceased work in?
(e.g., Grocery store, road construction, employment agency, ect)       _____________________________________

14.
How many years did the Deceased work in this occupation? ___________

15.Where is the Decedent's residents? (Physical address.  No P.O. Boxes please.)

Address: ___________________________________________________________

City: ___________________________ County/Province: _____________________

State: __________________________            Zip Code: _____________________

16.How many years did the Deceased live in the County/Province? (Total number of years) __________

17.What is the name of the person providing this information?

First Name: _____________________   Middle: _________________  Last: ___________________

18.What is the informants Relationship to the Deceased? ___________________________________

19.What is the Mailing address of the person providing this information?
(street and number or rural route number, city, or town, state, ZIP)

Address: ___________________________________________________________

City: ___________________________ County/Province: _____________________

State: __________________________            Zip Code: _____________________

Phone Number: ________________________  Other Phone: _______________________

20.What is the name of the Deceased's Spouse? (If married)

First Name: ________________   Middle:_____________ Last (Maiden Name): __________________

21.What is the Deceased's Father's Name?

First Name: _____________________   Middle: _________________  Last: ___________________

22.What state/foreign country was the Deceased's father born in?  ___________________________

23.What is the Deceased's Mothers Name?

First Name: ________________   Middle:___________ Last (Maiden Name): __________________

24.What state/foreign country was the Deceased's mother born in? __________________________

25.Where is the Deceased's final place of disposition going to be?

_______________________________________________________________________________

_______________________________________________________________________________
If the remains are to be buried please put down the name and location of the cemetery.  In the case of cremation, if the remains are going to a personal residents, please put down the name of the person in charge of the cremated remains and their address.  If the cremated remains are going to be scattered, please put down the place were the scattering will take place.

To the best of my knowledge, the information on this page is correct and accurate:

Signature of the person providing this information: _____________________________________