12425 Lewis Street, Suite 102 · Garden Grove, California 92840 Telephone (800) 678-0669 · Fax (714) 740-2764 · Establishment License Number FD1704

Thank you for trusting us with the care and services for your loved one.

The following documents attached to this file require signature(s) from the legal next of kin to the Deceased. In some cases that may be more than one person. Please contact us with any questions you may have while filling out these documents. Someone will be in touch with you as soon as we are able to assist.

Pages 1 & 2: These pages are to collect information for the Death Certificate. Please be as accurate as possible and write legibly. If the information is unknown, please indicate UNK or Not Applicable, N/A. Do not leave blank.

Page 3: Disclosure of Preneed Funeral Agreement: If the Deceased made prior arrangements with Cremation Society of Orange Coast, please indicate that here. If no prearrangements were made, select DOES NOT and sign on the bottom of the page where indicated.

Page 4: Authorization for Release of Remains: This allows our staff to transfer the Deceased into our care from the location where they died. Hospitals will not release without this form signed by the legal next of kin.

Page 5: Authorization to Accept or Decline Embalming: Embalming is not required by law and is not necessary for Simple Cremation Services. If Embalming is desired for purposes of a viewing, the deceased will be taken to the location listed, Douglass Mortuary, for preparation (Additional fees apply) If DO NOT is selected, the deceased will remain in refrigeration at the location of our crematory until the time of cremation.

Page 6 & 7: Authorization for Cremation and Disposition of Human Remains: These forms are authorizing cremation to take place and require INITIALS and SIGNATURES from all/majority of the legal next of kin. PG. 6- The first set of initials indicates whether you or anyone you have authorized is requesting to view the deceased prior to cremation. If requested, a time will be scheduled with your funeral director when available. Next, please initial whether the deceased has an implanted device that requires removal prior to cremation, i.e. pacemaker or defibrillator. PG. 7- Initial that you have read and understand the cremation process. Under the “Disposition of Remains” section only one of the lines need to be initialed, it is here where you are indicating how the urn will be released for final disposition. The first line indicates a Delivery Option is requested, this could mean you are requesting the funeral director deliver the urn to your home or to a cemetery for final disposition (Additional fees apply), the second line indicates we are to ship the urn via Priority Mail Express to a designated destination (Additional Fees apply), the third option (most common) indicates that you or someone authorized on your behalf will be picking up the urn from our office location in Garden Grove (scheduled appointments only). The Authorizing agent should sign on the bottom, if more than one exists, please use additional forms. If doing E-Signature please coordinate with your funeral director to send additional documents to the remaining next of kin. Valid Email addresses required.

Page 8: Declaration for Disposition of Cremated Remains: This form requires TWO SIGNATURES from the legal next of kin, one states that they have the legal right to control disposition and the other states that with that right cremation services are being contracted. All immediate NOK should sign this form, (i.e. Majority of children, if applicable)

Page 9: Service Agreement: This is the working contract with Cremation Society of Orange Coast, here you have the option to select different service options and indicate how many death certificates are to be ordered. Service Agreement will be totaled by your funeral director and any changes made will be sent back for approval prior to finalizing.

Fill in the Death Certificate information below and send it to CREMATION SOCIETY OF ORANGE COAST FD 1704

FAX: (714)740-2764 or EMAIL: anichols@cremationoc.com

(9 pages total)

(Please fill out all questions, if information is unknown simply indicate with UNK)

1. Name of the Deceased:

First name: __________________ Middle: ______________________ Last: ____________________________

2. Did the Deceased go by any other legal name?A.K.A (also known as) - If yes, include full name: __________________________________________________

3. Deceased's Date of Birth: __________________ Date of Death:_________________ Age:_____ Sex: _____

4. State or Foreign Country of Birth: ___________________________________________________________

5. Social Security Number of the Deceased: _______________________________________________________

6. Was the Deceased ever in the U.S. Armed Forces? __________ If yes, what Branch? _______________________If there will be Veterans Benefits such as burial at a National Cemetery or a Graveside Honor Guard ceremony, please sendthe Deceased’s Military Discharge Paperwork (DD214) with these forms in order for us to arrange these services.

7. What is the Deceased's Marital Status? Married Widowed Divorced Never Married

8. What is the highest level/degree of education obtained by the Deceased? ______________________________ (Ex: 7th Grade, High School Graduate, Associates, Bachelors, Doctorate)

9. What is the Deceased's race? You may enter up to three races. If Race is other, please specify:

___________________________ _____________________________ ______________________________

10. Was the Deceased Hispanic/Latino(a)/Spanish? NO YES please specify country of origin: ___________

11. If Race is American Indian, please specify Tribe (s):_______________________________________________

12. What was the Deceased's usual occupation/title:__________________________________________________

The type of work done for most of his/her life, only one option is allowed. Do not use RETIRED.

(Ex. grocery store, road construction, bank, education, etc.)

14. How many years did the Deceased work in this occupation? ________________________________________

15. Where is the Deceased's residence? (Physical addresses only, no P.O. Boxes please)

Address: _________________________________________________________________________________

City:____________________________________________County/Province: _____________________________

State:_____________________________________Zip Code: __________________________________________

13. What kind of business of industry did the Deceased work in?________________________________________

16. How many years did the Deceased live in the above listed County/Province? __________________________(1)

17. What is th name of the person providing this information?

First name: _________________________ Middle:____________________ Last: _________________________

18. What is the informant's relationship to the Deceased? ____________________________________________

19. What is the mailing address of the person providing this information?

22. What state or Foreign country was the Deceased's father born in?_________________________________

23. What is the Deceased's Mother's name?

First: _______________________ Middle: _____________________ Birth/Maiden name: ______________________

24. What state or Foreign country was the Deceased's mother born in?____________________________________

25. Where is the Deceased's Final Place of Disposition going to be?(Ex. Scatter at sea off the coast of Orange County, Residence of ...Please provide Name of Owner and full addressif placing at residence, Burial in Cemetery-Provide name and city, etc.)

Address: ___________________________________________________________________________________

City: __________________________ State: _______________________ Zip Code: _______________________

Phone Number: _____________________________ Other Phone: _____________________________________

Email Address: ______________________________________________________________________________

20. What is the name of the Deceased's Spouse? (If married)

First:_________________________Middle:_______________________Birth/Maiden Last: ______________________

21. What is the Deceased's Father's name?

First: ______________________Middle: _____________________ Last: _________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________

_________________________________________________________________________________________To the best of my knowledge, the information on this page is true and accurate:

Signature of person providing this information: _________________________________________________ (2)

Disclosure of Preneed Funeral Agreement

The funeral establishment, ___ C_r_e_m_at_i_o_n_S_o_c_ie_t_y_o_f_O_ra_n_g_e_C_o_a_s_t _________ _ (funeral establishment name)

license number FD 1704 , DOES __ , DOES NOT ___ (check one) have a preneed arrangement, as

defined below, made by or on behalf of ________________________ _

.....

(name of decedent)

If the funeral establishment does have a preneed agreement, complete the following:

In compliance with Business and Professions Code Section 7745, the funeral establishment has presented to the person named below a copy of any preneed agreement which has been signed and paid for in full, or in part by, or on behalf of the deceased and is in the possession of the funeral establishment.

Signature of funeral establishment representative Date

"Preneed arrangement," "preneed agreement" or "preneed" is written instruction regarding goods or services or both goods and services for final disposition of human remains when the goods or services are not provided until the time of death, and may be either unfunded or paid for in advance of need.

Funeral Establishment's Responsibility- Business and Professions Code Section 7745 requires a funeral establishment to present to the survivor of the decedent or the responsible party a copy of any preneed agreement in its possession which has been signed and paid for in full, or in part by, or on behalf of the deceased. Business and Professions Code Section 7685.6 requires a copy of any preneed arrangements to be disclosed prior to drafting any contract for funeral goods or services. The funeral establishment may present the copy in person, by certified mail, or by facsimile transmission, as agreed upon by the person with the right to control disposition. A funeral establishment that knowingly fails to present a preneed agreement as required is liable for a civil fine equal to three times the cost of the preneed agreement, or one thousand dollars ($1,000), whichever is greater.

You may contact the Cemetery and Funeral Bureau for more information on funeral, cemetery or cremation matters or to file a complaint against a licensee:

Cemetery and Funeral Bureau 1625 North Market Blvd., Suite S-208 Sacramento, CA 95834 916-574-7870

Signature of the survivor or responsible party

Print name of the survivor or responsible party

Signature of funeral establishment representative

Print name of funeral establishment representative

The funeral establishment must:

Date

Date

Title

• Give a copy of the completed statement to the survivor or responsible party.• Retain the original or a copy of the completed disclosure statement on file for not less than one ( 1) year

after the preneed account has been audited by the Bureau or seven (7) years from the date thedisclosure statement was made, whichever comes first.

21F1 (10/03)

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Amy Nichols FDR 3584

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SM

Douglass

Cremation Society OF ORANGE COAST

“A FULL SERVICE CREMATION AND FUNERAL PROVIDER”

12425 Lewis Street, Suite 102 · Garden Grove, California 92840

Telephone (800) 678-0669 · Fax (714) 740-2764 · Establishment License Number FD1704

Authorization for Release of Remains

Name, Address & Phone Number of Place of Death

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________ Phone: ________________________________

Please read and answer all questions before signing.

WAS THE DECEDENT LEGALLY MARRIED AT THE TIME OF DEATH?___________

DOES THE DECEDENT HAVE ANY LIVING ADULT CHILEREN (18 years & over)?___________

HEALTH AND SAFETY CODE * CHAPTER 3 * CUSTODY AND DUTY OF INTERMENT

7100. The right to control the disposition of the remains of a deceased person, unless other directions have been given by the decedent, vests in, and the duty of interment and the liability for the reasonable cost of interment

of such remains devolves upon the following in the order named: (a) An Agent under Power of Attorney for

Health Care (b) The surviving competent spouse. (c) The sole surviving competent adult child or majority of the adult children of the decedent. (d) The surviving competent parent or parents of the decedent. (e) The

surviving competent adult person or persons respectively in the next degrees of kindred in the order named by

the laws of California as entitled to succeed to the estate of the decedent. (f) The Public Administrator when

the deceased has sufficient assets.

Executed this day of , at City State ______

“WARNING: THE PERSON SIGNING THIS ORDER FOR RELEASE IS LIABLE FOR ALL DAMAGES CAUSED

BY ANY UNTRUTHFUL STATEMENTS CONTAINED IN THIS DOCUMENT.

(HEALTH AND SAFETY CODE SECTION 7110).”

Please release the remains of the deceased, _____________________________________________________

To: Cremation Society of Orange Coast – 12425 Lewis Street #102, Garden Grove, CA 92840 including their agents.

I understand that for storage or embalming purposes the decedent may be transported to the following

licensed establishment: Gateway Crematory 1410 S. Acacia Ave. #D Fullerton, CA 92831 (holding center forcremation) OR Douglass Family Mortuary-3363 East Imperial Highway, Lynwood, California 90262 (holding for embalming). The undersigned hereby represents that he/she has the legal right to control disposition of the remains of the

decedent.

I Declare Under Penalty of Perjury that the foregoing is true and correct.

XSigned: ______________________________________________ Relationship: _________________________

Address: _____________________________________________ City: ________________________________

State: ______________________ Zip: _________________ Phone: ___________________________________ 2020

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AUTHORIZATION TO ACCEPT OR DECLINE EMBALMING

TO: Cremation Society of Orange Coast Fo1104(Funeral Establishment Name)

RE: -------------------

(Decedent)

Embalming is the addition to, or the replacement of, body fluids by chemical preservatives or the application of chemical preservatives for the temporary preservation of the body. I understand that embalming is not required by law.

I, _____________ , do_do notn(check one) request embalming. I understand that for storage or embalming purposes the decedent may be transported to the following location:

Douglass Family Mortuary - 3363 East Imperial Highway, Lynwood, CA 90262 (Location Name and Address)

The undersigned hereby represents that he/she has the legal right to control disposition of the remains of the decedent.

-•-►Signed: _____________ , Relationship to Decedent: _____ _

Executed this __ day of _________ , at __________ _ (Month) (Year) (City and State)

This section is to be completed by the funeral establishment if authorization to accept or decline embalming is obtained orally.

The above statement regarding embalming and storage was read and/or provided to -------=,------' Relationship to Decedent: _______ who did D did notD (check one) authorize embalming at the above named funeral establishment. Telephone Number: ___________ _ Date and time authorization granted: ______________

This section is to be completed by the funeral establishment representative who is executing this authorization to accept or decline embalming.

I declare under penalty of perjury that the foregoing is true and correct. Executed this __ day of _______2020 , at

(Month) (Year) (City and State)

Amy Nichols Funeral Establishment Representative (Print Name) Funeral Establishment Representative (Signature)

12-AUTH (rev. 11/14)

Garden Grove________

X

2020

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Gateway Crematory CR-2971410 S. Acacia Ave. #D Fullerton, CA 92831

(714) 535-3715

Authorization for Cremation and Disposition of Human Remains

[Note: This is an important legal document which you should read carefully before signing.]If you have any questions please ask your funeral Counselor and or,

"For more information on Funeral, Ceremony, and Cremation matters, contact:Department of Consumer Affairs Cemetery and Funeral Bureau, 1625 North Market Blvd. Suite S-208 Sacramento, CA

95834(916) 574-7870"

The Cremation Process is performed according to California Law. There can be no Allowance for ethnic or religious variation.Subject to the rules and regulations of Gateway Crematory and any applicable Federal, State, Local Laws, or Ordinances theundersigned hereby certifies, warrants and represents that I/We have the full legal right and authority to authorize Gateway Crematory(hereafter the "Crematory") to perform the cremation of the remains of:

Casket/Containers: Gateway requires either a casket or alternative cremation container. All caskets and alternative containers mustmeet the following standards: 1) be composed of combustible materials suitable for cremation; 2) be able to be closed to provide acomplete covering for the human remains; 3) be resistant to leakage or spillage; 4) be sufficient for handling with ease; and 5) be ableto provide protection for health and safety of Crematory personal. The Crematory is authorized to inspect the casket or alternativecontainer, including opening it if necessary. In the event there is leakage or damage, the Crematory may contact the Funeral Homedirectly for instructions. Metal, Plastic, Fiberglass Caskets or Cremation Containers will not be allowed to be cremated. TheCrematory is authorized to remove and dispose of handles, ornaments and any other non-combustible items in any lawful manner itdeems appropriate. These may include, but not limited to hinge, handles, latches, etc. In the event the urn or other container isinsufficient to accommodate all of the cremated remains, the excess will be placed in a separate receptacle (plastic urn) at no charge. The receptacle (plastic urn) will be kept with the primary receptacle and handled according to the disposition on this form.

Pacemaker, Prostheses, and Radioactive Devices: Pacemakers and prostheses, as well as any mechanical or radioactive devices or implants in the decedent, may create a hazardous condition when placed in the cremation chamber. It is imperative that such items beremoved prior to cremation. If the Crematory is not notified of these devices and implants, and not instructed to remove them, then theperson(s) authorizing the cremation will be held responsible for any damages caused to Gateway Crematory personnel or equipmentby such devices or implants. By initialing this paragraph, I/We give permission to the Crematory, Funeral Home, or Staff to removethe surgical hardware as referenced above prior to cremation. The Funeral Home and or the Crematory are authorized to dispose of thedevice(s) as deem appropriate.

[FIRST NAME] [MIDDLE NAME] [LAST NAME]

Approximate Weight[Decedents Usual Address]

Place of Final Disposition

I hereby DECLINE to View the Decedent at the Crematory; INITIAL

; INITIAL

Funeral Home handling the arrangements:

Casket or Cremation Container Selected / Urn Selected

Pacemaker; YES OR NO (Circle One) (INITIAL)

(Hereafter the "Deceased/Decedent"), and to arrange final disposition of the cremated remains as follows:

I REQUEST a Viewing of the Decedent at the Crematory; Date/Time

ID Viewing or Witness the insertion into the cremation chamber (Check One if desired)

(Hereafter the Funeral Home)CREMATION SOCIETY OF ORANGE COAST FD1704

Cardboard Cremation Container Durable Plastic Urn

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The Cremation Process:The Human body burns with the casket, container, or other materials in the cremation chamber. Some bone fragments are notcombustible at the incineration temperature and, as a result in the cremation chamber. During the cremation, the contents of thechamber may be moved to facilitate incineration. The chamber is composed of ceramic or other material which disintegrates slightlyduring each cremation and the product of that disintegration is commingled with the cremated remains. Nearly all of the contents ofthe cremation chamber, consisting of the cremated remains that disintegration chamber material, and small amounts of residue fromprevious cremations, are removed together and crushed, pulverized, or ground to facilitate inurnment. Some residue remains in thecracks and uneven places of the chamber. Periodically, the accumulation of this residue is removed and scattered at sea in accordancewith State Laws. The acknowledgement shall be filed and retained, for at least five years, by the person who disposes of the remains. Due to the nature of the cremation process, any personal possessions or valuable materials such as dental gold or silver, or jewelry (as well as and body prostheses or dental bridgework) that are left with the Decedent and are not removed from the casket or cremationcontainer prior to cremation may be destroyed and become non-recoverable, or if not destroyed, they will be handled by theCrematory in accordance with the instructions on the authorization. If you desire to save such items, the Authorizing Agent must makearrangements to remove any such possessions or valuables prior to cremation. After the cremated remains are removed from thecremation chamber, all non-combustible materials (insofar as possible), such as dental bridgework, body prostheses, and materialsfrom the casket or containers such as hinges, latches, etc., will be separated and removed from the human bone fragments by visible ormagnetic selection. Unless specifically requested to return such items in writing, the Crematory is authorized to dispose of thesematerials with similar materials from other cremation in a non-recoverable manner, so that only the human bone fragments willremain. There may be small non-combustible material the operator may not visibly see and be placed in the urn with the human bonefragments. When the cremated remains are removed from the cremation chamber, the skeletal remains often contain recognizablebone fragment. After the bone fragments have been separated from the other material, they will be mechanically processed(pulverized), which includes crushing particles unrecognizable as human remains, prior to placement into the designated container.

DISPOSITION OF CREMATED REMAINS

I/We authorize the Crematory to release the cremated remains of the Decedent to the possession and custody of the Funeral Home. I/We understand that the services and obligation of the Crematory shall be fulfilled when the cremated remains of the Decedent are released to the possession and custody of the Funeral Home. I/We hereby authorize the Funeral Home to arrange for the disposition of the Decedent as stated below. I understand that in the event the cremated remains have not been permanently interred or picked up by me or my designated representative within 20 days from the date of cremation, The Funeral Home is authorized to lawfully dispose of the unclaimed cremated remains pursuant to statutes. : (Choose One)

Authorizing Agent: An Authorizing Agent is the person(s) having the right to control the disposition of the Decedent pursuant toHealth and Safety Code Sec. 7100.1.) Decedent, 2) An Agent under power of attorney for Health care, 3) Spouse or RegisteredDomestic Partner, 4) Adult Children, 5) Parents, 6) Other surviving competent adult Kin. By signing this Authorization for Cremationand Disposition, I/We acknowledge and agree that I/We have read and understood every part of this Authorization, including the factthat the process of cremation is irreversible, and I/We nevertheless desire that the Deceased's remains be cremated in accordance withthis authorization. I/We agree to indemnify, release and hold Gateway Crematory, The Funeral Home, Their affiliates, Employees and assigns, harmless from any and all losses, damages, cost or expense resulting from the Funeral Home's and Crematory's reliance on orperformance consistent with directions, declaration, representation, authorization and agreements herein, including, but not limited to,any delay in, or damage arising from the transportation of the human remains or cremated remains of the Decedent, and liability or causes of action in connection with the cremation and disposition of the cremated remains as authorized herein. I/We warrant that all representations and statements made herein are true and correct. I/We have either identified or waived my/our rights of identification of the Decedent that were delivered to the Funeral Home as the Decedent and I/We have authorized the Funeral Home to deliver theDecedent to the Crematory.

(INITIAL)

(INITIAL)

(INITIAL)

(INITIAL)

Deliver said cremated remains to:

I appoint the Funeral Home as my agent to make shipment of said cremated remains via theU.S. Postal Service, I understand that the Funeral Home assumes No responsibility after delivery.

SHIP TO:

RELEASE TO:

Executed at on

Signature of Authorized Agent:

Printed Name:

Relationship

Phone #

Deceased: _________________________________,

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DECLARATION FOR DISPOSITION OF CREMATED REMAINS

I/We hereby declare (my remains) or (the remains of) in Name of Person arrangements are for

the possession of , will be cremated byName of Funeral Establishment and Telephone Number

and shall be disposed of in the followingName of Crematory and Telephone Number

manner (Note 1): Manner, Location and Other Details of Disposition

Attach additional pages if necessary

Name of person(s) with the legal right to control disposition (Note 2):

Signed Date Person(s) with legal right to control disposition to Self, if pre-arranging

Signed Date Person(s) with legal right to control disposition

Signed Date Person(s) with legal right to control disposition

Signed Date Person(s) with legal right to control disposition

Name of person(s) contracting for cremation services:

Signed Date Person(s) contracting for cremation services

Signed Lic. # Date Funeral Director, Employee, or Agent for Funeral Establishment If a Funeral Director

Note 1: See Health & Safety Code Sections 7054, 7054.6, 7116, 7117 for legal dispositions of cremated remains.

Note 2: See Health & Safety Code Section 7100 for the list of person(s) with the legal right to control disposition of human remains.

IMPORTANT: Business and Professions Code § 7685.2(b) requires Funeral Establishments to complete this form, provided

by the Cemetery and Funeral Bureau, when making arrangements for cremation. Failure to complete this form may result in

disciplinary action by the Bureau. This declaration does not replace the written authorization to cremate required by Health

and Safety Code Sections 7110 and 7111.

NOTICE REGARDING CREMATED REMAINS

A person having the right to control disposition of cremated remains may remove the remains in a durable container from the place of cremation or interment, pursuant to Section 7054.6 of the Health and Safety Code.

If the cremated remains container cannot accommodate all cremated remains of the deceased, the crematory shall provide a larger cremated remains container at no additional cost, or place the excess in a second container that cannot easily come apart from the first, pursuant to Section 8345 of the Health and Safety Code

California Department of Consumer Affairs, Cemetery and Funeral Bureau www.cfb.ca.gov (Rev. 10/2008)

Amy Nichols

Cremation Society of Orange Coast (800)678-0669

Gateway Crematory - Fullerton, CA

X

X

3584

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http:www.cfb.ca.gov

Simple Cremation Package $690Included Included

Included

Durable Plastic Urn Included

X

Cardboard Cremation Container Included

Online Obituary CremationOC.com Included

if requested $75if requested $125

NON-WITNESS if requested $75

if requested $295

if requested $195

Included

Options to Upgrade Available

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$12.00

Additional $200

CSOC Front Letter.pdfCSOC SIMPLE CREMATION.pdf2020 SIMPLE CREMATION FORMS.pdfSimple Cremation GATEWAY.pdfVitals FILL INBlank PageBlank Page

Discl pre need - Fill inAuthorization for release FILL INEmbalming AuthorAmy Nichols FILL INDISPOSITION FORM FILL INContract Fill NEW-BLANK

GATEWAY CREMATORY AUTHO.pdf

AKA also known as If yes include full name: Date of Birth: Date of Death: Age: Sex of Deceased: 4 State or Foreign Country of Birth: 5 Social Security Number of the Deceased: Military?: If yes what Branch: Highest Degree Obtained: Race 1: RACE 2: RACE 3: Tribe name: 12 What was the Deceaseds usual occupationtitle: 13 What kind of business of industry did the Deceased work in: 14 How many years did the Deceased work in this occupation: Address of Deceased: City of Deceased: CountyProvince of Deceased: State of Deceased: Zip Code of Deceased: Years in county: MARRIED: OffWIDOWED: OffDIVORCED: OffNEVER MARRIED: OffHISPANIC: OffHispanic Origin: Informant's First Name: Informant's Middle Name: Informant's Last Name: Informant's relationship to deceased: Informant's Address: INFORMANT'S CITY: INFORMANT's STATE: INFORMANT'S ZIP CODE: Phone Number: Other Phone: Email Address: Spouse's First Name: Spouse's Middle Name: Spouse's Last Name: Father's First Name: Father's Middle Name: Father's Last Name: Father's Birthplace: Mother's First Name: Mother's Middle Name: Mother's Maiden Name: Mother's Birthplace: DOES HAVE PRENEED: OffNO PRENEED: OffName of Place of Death: Address of Place of Death: Address of Place of Death 2: Phone # of Place of Death: WAS THE DECEDENT LEGALLY MARRIED AT THE TIME OF DEATH: DOES THE DECEDENT HAVE ANY LIVING ADULT CHILEREN 18 years over: NAME OF DECEASED: Address: City: State: Zip: Check Box15: OffCheck Box16: OffNEXT OF KIN: NOK RELATIONSHIP: DAY: MONTH: CITY: STATE: FIRST NAME OF DECEASED: MIDDLE NAME OF DECEASED: LAST NAME OF DECEASED: APPROX: WEIGHT:

Final Disposition of Urn: ADDRESS OF DECEASED: Initial3_es_:signer:initials: PACEMAKER: OffID VIEW: OffWITNESS: OffDELIVER TO ADDRESS IN ORANGE COUNTY ($75): SHIPPED TO ADDRESS IN UNITED STATES ($125): PICKUP FROM OFFICE IN GARDEN GROVE (FREE): LOCATION SIGNED: NOK PHONE: Initial7_es_:signer:initials: Initial8_es_:signer:initials: Initial9_es_:signer:initials: Initial10_es_:signer:initials: Signature11_es_:signer:signature: Date12_es_:signer:date: Address/Description of Disposition: Place of Disposition Line 3: NEXT OF KIN 4, 5, 6: TODAY'S DATE: Date of First Signature of Person(s) with legal right to control disposition: Date of Second Signature of Person(s) with legal right to control disposition: Date of Third Signature of Person(s) with legal right to control disposition: NEXT OF KIN 2: NEXT OF KIN 3: Address of Purchaser: Check Box17: OffCheck Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffNUMBER OF DCS: Check Box1: OffDC TOTAL: URN UPGRADE REQUEST: