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FUNERAL PLANNING
California Funeral Alternatives
1020 E. Pennsylvania Avenue
Escondido, CA 92025
Ph. 760-737-2890 - Fax 760-737-2892
FD1624
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VITAL STATISTICS - FOR DEATH CERTIFICATE
INFORMANT: Please read carefully
The informant is a person who has knowledge of vital statistics that will be placed on the
legal death certificate document. Once this document has been filed with the State of
California, only a legal affidavit can change any information. This change will be on an
amendment to the original document. Any areas that are left blank, will require
"UNKNOWN" - all areas must be filled in.
All spelling and information must be correct!
Please use tabs to type information
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Decedent's Name:
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Also Known As (other legal names):
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Date of Birth:
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Age:
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Sex:
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State of Birth:
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Social Security #:
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Ever in US Armed Forces:
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Marital Status (at time of death):
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Education (years completed) ( 0,3rd,11, H.Grad, Some college, Bachelors, Masters, Professional
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Was Decedent Hispanic/Latino/Spanish?
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If yes, which one?
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Decedent's Race (may list up to 3 races):
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Occupation: (Elementary Teacher, Homemaker, Electrical Engineer, Accountant)
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Type of Business or Industry: (Grocery Store, Aerospace, Road Construction)
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How many years in the above occupation?
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Decedent's Residence: (Street and number or location)
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Informant's Name:
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Relationship to Deceased:
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Informant's Mailing Address:
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Surviving Spouse's Name:
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Father's Name:
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Birth State:
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Mother's Name:
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Birth State:
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Type of Final Disposition: (Cremation or Burial)
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Place of Final Disposition:
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Veterans - If you desire to have burial at a Veteran's Cemetery, we must have a copy of your honorable military discharge (DD214)
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If you are faxing this document to California Funeral Alternatives. Please print, sign and date the document on the bottom, fax to
760-737-2892. You may also bring this document with you when you have set an appointment to meet with us.
If you are submitting through the Internet, please call and confirm that we have received this information. (Office hours 9-4PM M-F)
Release and Indemnification:
The Informant hereby releases and agrees to indemnify and hold harmless California Funeral Alternatives, it's affiliates, officers, agents,
employees and representatives, of any and all claims, demands, damages, liabilities or causes of action of any nature whatsoever, and any
attorneys' fees and costs of litigation, that the Informant or any other person or entity may have or claim to have, now or in the future, arising
out of the vital statistic information for the legal death certificate document. I agree that all the above information is true to the best of my
knowledge.
Signature:______________________________________________ Informant
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Informant's Name:
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Informant's Phone #'s:
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Home
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Cell
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CFAOffice Use Only:
Informant has confirmed as per telephone: Date: Time: Initials___________
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