|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, Sacramento.
First, Middle & Last Name:
Also Known As: (Legally)
Date of Birth:
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
Spanish? 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:
Informants Full Name & Relationship:
Mailing Address & Phone No.:
Spouse & Parent Information:
Spouse's Full Name including Maiden:
Address if different than Decedent:
Father's Full Name:
Place of Birth:
Mother's Full Name/Maiden:
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)