California Funeral Alternatives
Escondido  760-737-2890     Poway 858-842-3000
To the Informant, who is completing this form:
When you sign or fax this document you are stating that all information is true to the best of your knowledge.
Please check all spelling.  This information will be placed on the Death Certificate, changes to the
certificate can only be made by amending the original and submitting those changes to the
County of San Diego, Office of Vital Statistics and the Death Registration Office, State of California, S

Decedent Information:

First, Middle & Last Name:

Also Known As: (Legally)

Date of Birth:

Age:             Sex:

State of Birth:
Born outside of US, Country only

Social Security No.

Ever in US Armed Forces:
Yes, No, Unknown

Marital Status:  Married, Widowed,
Never Married, Divorced:

Education:  Yrs/Degree, 11th..HS Grad,
Some Clge.,Bach., Mstr., Doct., Profnl.

Was Decedent Hispanic/Latino or
If yes, what country?

Race, up to 3 Races:

Usual Occupation:   
(Not Retired)

Type of Business:

Years in Occupation:

Residence  Street Address,
City & Zip:

How Many Years In the County:

Informant Information:

Informants Full Name & Relationship:

Mailing Address & Phone No.:

Spouse & Parent Information:

Spouse's Full Name including Maiden:

Address if different than Decedent:
Phone Number:

Father's Full Name:
Place of Birth:

Mother's Full Name
Place of Birth:

Funeral Director's Information:

Place of Final Disposition:
Such as, Residence, Cemetery, etc.
Full Address of Disposition:

Type of Disposition:  Cremation,
Casket Burial, Scattering at Sea,
Return to Residence, Viewing:

Informant's Signature & Date, if faxed
(fax # 760-737-2892)