Vital Statistic Information:                                                    

The following information is required by the State of California. You may submit vital statistics information with us on-line by filling in the form below. If filling out on behalf of someone else, please remember to put in info pertaining to them.

(You would be informant)

NAME: (First, Middle, Last)            

AKA                                                    

HEBREW NAME                              

DATE OF BIRTH (mm/dd/ccyy)     

BIRTH STATE OR COUNTRY       

EVER IN U.S. ARMED FORCES   YES NO UNKNOWN

IF YES BRANCH OF MILITARY     

MARITAL STATUS                             MARRIED WIDOWED DIVORCED NEVER MARRIED

HIGHEST GRADE OF EDUCATION, HIGH SCHOOL GRADUATE, SOME COLLEGE NO DEGREE

OR TYPE OF DEGREE                  

RACE                                                 

OCCUPATION WHEN WORKING    (NOT RETIRED)

YEARS IN OCCUPATION               

RESIDENCE ADDRESS                

RESIDENCE-City, State Zip          

YEARS AT RESIDENCE                 

SPOUSE                                              (MAIDEN NAME FOR WIFE)

NAME OF FATHER                             (FIRST, M, LAST)

FATHERS PLACE OF BIRTH        

NAME OF MOTHER                           (FIRST, M, LAST)

MAIDEN NAME OF MOTHER        

MOTHERS PLACE OF BIRTH      

SYNAGOGUE AFFILIATION          

OWN CEMETERY PROPERTY AT:

MISCELLANEOUS NOTES AND INSTRUCTIONS:

NEXT OF KIN / INFORMANT/ OR SELF:

NAME (First, M, Last)                      

ADDRESS OF INFORMANT           

ADDRESS City, State, Zip              

PHONE NUMBER  (HOME)          

CELL                                                 

EMAIL                                                

PLEASE SELECT FROM FOLLOWING OPTIONS:

                                              PLACE INFO ON FILE

                                              PLEASE CONTACT ME TO SET UP AN APPOINTMENT

                                              PLEASE SEND ME INFO ON PRE PLANNING

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