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A2A Vitals

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DATE OF BIRTH mm/dd/yyyy

AGE Yrs

SEX

DATE OF DEATH

HOUR (24 HOURS)

BIRTH STATE/FOREIGN COUNTRY

SOCIAL SECURITY NUMBER

EVER IN U.S. ARMED FORCES?

Yes

UNK

MARITAL STATUS-CHECK ONE

MARRIED

WIDOWED

DIVORCED

NEVER MARRIED

UNKNOWN

EDUCATION (Highest Grade or Degree) –CHECK ONE

0-DID NOT COMPLETE ONE YEAR

GRADES 1-11

GRADE

H.S. DIPLOMA/GED

SOME COLLEGE (NO DEGREE)

ASSOCIATE

BACHELORS

MASTERS

14/15. WAS DECEDENT SPANISH/HISPANIC/LATINO

Yes

DECEDENT’S RACE- UP TO 3 RACES MAY BE LISTED (optional)

FINAL DISPOSTION (CHECK ONE)

BURIAL AT CEMETERY

KEEP AT RESIDENCE

SCATTER AT SEA BY MORTUARY

ADDRESS OF CEMETERY OR RESIDENCE

NOTES:

Does this person have a PACEMAKER

Yes

Is this person Contagious?

Yes

I have read the above information and verify that the information is true and correct.

DATE

Examples of items that may require a “Certified Copy” are: (optional)

• Social Security • Life Insurance Policies • Pension Funds • Bank Accounts • Saving Accounts • Certificates of Deposit
• County Recorders Office (Property) • Securities (Stocks/Bonds) • Department of Motor Vehicles (Automobile)

Mail Certified Copies to Informant

Yes

No - Mail Certified Copies to Informant

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Los Angeles, CA 90039
Tel: (323) 804-1944
Fax: (323) 663-3323

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340 W. San Rafael Dr.
Palm Springs, CA 92262
Tel: (323) 804-1944

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