Become a Member Now, Plan Later

Personal Information Payment Options
Please Complete All Fields.
This information is required in order to fill out the death certificate.
 
Please put UNKNOWN or N/A when information is unavailable or does not apply.
 Services For:
*First Name:
Middle Name:
*Last Name:
*Street Address:
Apt/Suite:
*City:
*State:
*Zip Code:
*County of Residence:
*Years in County:
*Social Security Number:
*Date of Birth:
*City & State/Country of Birth:
*Race:
*Sex: Female Male
*Marital Status:
Telephone Number:
Citizen of what Country:
*Degrees Earned:
*Last Occupation:
(Cannot use Retired)
*Years in Occupation:
Usual Employer:
Kind of Business / Industry:
 Spouse:
*First Name:
*Last Name:
*Maiden Name:
  Check if deceased
 Father:
*First Name:
Middle Name:
*Last Name:
*Birth State/Country:
(if outside of USA)
  Check if deceased
 Mother:
*First Name:
Middle Name:
*Maiden Name:
*Birth State/Country:
(if outside of USA)
  Check if deceased
 Military Records:
*Veteran:  Yes  No
Branch of Service:
  Person Making Arrangements:
*First Name:
Middle Name:
*Last Name:
*E-Mail:
*Address:
*City:
*State:
*Zip Code:
*Phone:
*Relationship:
  Legal Next-of-Kin:
Please select one of the following options and enter your information:
I am a person acting as DPOA and/or have a California Advanced Health Care Directive for the deceased.
I am the spouse of
I am the registered domestic partner of
I am the child of (**please list all surviving adult children**)
Are you making arrangements for your child? (**please list both surviving parents**)
Are you making arrangements for your brother or sister? (**please list all surviving adult brothers and sisters**)
I am making arrangements for another family member
(**please list all surviving family members**)
  Special Instructions:
  How Did You Hear About Us?
Please select:
 

Print this form

NOTE: Fields marked with an asterisk (*) are required. Any information you submit will be held in the strictest confidence. We do not release any information to outside parties under any circumstances.

 

2701 182nd Street    |    Redondo Beach, CA  90278  |    (310) 792-7585    |   
Home   |   Contact Us   |   Maps & Directions   |   Price Info
High Assurance SSL Certificate
© Copyright  2010-2018 Cremation Society of the South Bay and FuneralNet®

 

Infinite Menus, Copyright 2006, OpenCube Inc. All Rights Reserved.