Death Certificate Worksheet

 

We are required by the State of California to collect this information to complete the State of California Death Certificate. If you do not feel comfortable sending this information online you can provide it in person at our arrangement.

If you have not already scheduled an arrangement with us, please call our office between the hours of 9AM and 5PM at 323-446-2233 to set-up a time to meet with a director.

We understand that you may not have access to all of the details below, you may submit as little or as much as you feel comfortable.  Please use this as a reference guide to help understand what questions we are required to ask you during our arrangement. 

DECEDENT INFORMATION
GENDER
DATE OF DEATH
DATE OF DEATH
DATE OF BIRTH
DATE OF BIRTH
PLACE OF RESIDENCE
ADDRESS
ADDRESS
CANNOT BE PO BOX
EDUCATION & OCCUPATION
VETERAN
Example: Professor, Accountant, Homemaker, Funeral Director
Example: Professor/Education, Accountant/Law, Homemaker/Home, Funeral Director/Funerals
MARITAL STATUS AT TIME OF DEATH
Cannot be 'Single'
PARENT'S INFORMATION & INFORMANT
First, Middle, Last & State or Country of Birth
First, Middle, Maiden & State or Country of Birth
THIS IS THE NAME OF THE PERSON SUPPLYING INFORMATION FOR DEATH CERTIFICATE
INFORMANT'S ADDRESS
INFORMANT'S ADDRESS
CANNOT BE PO BOX
PLACE OF DEATH & INTERMENT INFORMATION
RESIDENCE, NAME OF HOSPITAL, NAME OF SKILLED NURSING FACILITY
DOCTOR'S PHONE NUMBER
DOCTOR'S PHONE NUMBER
CHARGE NURSE STATION NUMBER
CHARGE NURSE STATION NUMBER
THE NURSE IS OFTEN IN CHARGE OF RELEASING THE BODY INTO OUR CARE. OBTAINING THEIR DIRECT NUMBER AIDES IN EXPEDITING THIS PART OF THE PROCESS
NURSE STATION FAX NUMBER
NURSE STATION FAX NUMBER
WE WILL NEED TO FAX A SIGNED RELEASE FROM THE NEXT OF KIN TO THE NURSE OR DECEDENT AFFAIRS. IF YOU ARE ABLE TO OBTAIN THIS NUMBER IT AIDES IN EXPEDITING THE PROCESS.
SERVICE INTEREST
THIS INFORMATION IS ALSO PLACED ON YOUR ASSOCIATED DISPOSITION/BURIAL/TRANSPORTATION PERMIT. IF TAKING HOME PLEASE WRITE YOUR NAME AND ADDRESS. IF IT IS A CEMETERY PLEASE WRITE THE NAME OF THE CEMETERY. WE CAN DISCUSS THIS FURTHER DURING THE ARRANGEMENT.