THE OMEGA SOCIETYREGISTRATION APPLICATION

Please complete the following information on the person for whom arrangements are being made. We will use this information to type a death certificate. Please print clearly and fill out completely, leaving no blanks.

Write UNK when information is unknown.

Full Legal Name

Legal AKA (if applicable)

1577 North Main St.Orange, CA 92867www.omegasociety.com

Phone: 714-754-7781FAX: 714-754-7103

Sex Race

Street Apt. #

City State Zip County

Phone (H) Social Security #

Date of Birth Age # Living ChildrenYears Resided in County

( )

Birthplace (State Only, or Country if not US) Highest Education

Fathers Full Name

Mothers Full Maiden Name

BirthplaceState Only

BirthplaceState Only(Maiden Name)

(Last or Maiden Name, if female)Surviving Spouses Full Name

(Maiden Name, if female)

Marital Status (Current): Married Never Married Widowed Divorced State Registered Domestic Partner

Decedents Occupation # Years in Profession

Type of Industry/Business Veteran: Yes No

Immediate Next of Kin Relationship

Street Apt. #

City State Zip

Phone (H) (Email)( ) (Cell)( )

Second Next of Kin Relationship

Street Apt. #

City State Zip

Phone (H)( ) (Cell)( )

(Used on death certificate)

FOR MORE INFORMATION ON FUNERAL, CEMETERY 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

SIGNATUREDate(To be signed by authorized next of kin, or self signed)

(First) (Middle) (Last)

(For burial at a veterans cemetery, please provide a copy of DD-214 Honorable Discharge Form)

(First) (Middle) (Last)

(First) (Middle)

(First) (Middle)

(prior to retirement)

(Email)

AUTHORIZATION TO RELEASE

AUTHORIZATION TO CREMATE

This is my authorization to release the remains of:

to THE OMEGA SOCIETY1577 North Main St., Orange, CA 92867

Phone: 714-754-7781 FAX: 714-754-7103

SIGNATURE Date(To be signed by authorized next of kin, or self signed)

RelationshipPrint Name

SIGNATURE Date(To be signed by authorized next of kin, or self signed)

RelationshipPrint Name

The undersigned hereby requests and authorizes THE OMEGA SOCIETY or its assigns, in accordance with and subject to its rules and regulations, to cremate the remains of:

(Please print the full name of the person for whom arrangements are being made.)

(Please print the full name of the person for whom arrangements are being made.)

and certifies and represents that he or she has the right to make such authorization and agrees to hold THE OMEGA SOCIETY and its assigns, harmless from any liability on account of said authorization and cremation. THE OMEGA SOCIETY disclaims all responsibility for rings, jewelry, gold or other valuables left on or with the deceased.

Disposition Permit To Read As Follows:

SCATTER AT SEA:

RETURN TO FAMILY: (for Special Disposition as provided in Health and Safety Code)

CEMETERY INURNMENT: Complete Cemetery Name:

If at Sea, By Family: To be scattered off the coast of

Return to whom:

Cemetery Address (Street):City

County

Unwitnessed Sea(by Omega, no family present)

Private Sea Charter(by Omega, family to witness)

At Sea, by Family(Family to scatter themselves)

To be picked up Omega to ship (additional charge) Phone:

State County ZipPhone:

To be picked up Omega to ship (additional charge)

I certify the deceased does does not have a pacemaker or other battery operated implant.

CHARGES: I understand that I am to pay THE OMEGA SOCIETY all current charges in full at time services are contracted, unless account is prepaid.

WORKSHEET FOR EDUCATION AND RACE/ETHNICITY

DECEDENTS EDUCATION-Check the box that best describes the highest degree or level of school completed at the time of death.

Enter appropriate information in box No. 13

0-11th grade. Enter highest year completed:

12th grade, but no diploma.Enter 12 ND

High school graduate or GED completed. Enter HS GRADUATE

Some college credit, but no degree. Enter SOME COLLEGE

Associate degree (e.g., AA, AS). Enter ASSOCIATE

Bachelors degree (e.g., BA, AB, BS). Enter BACHELORS

Masters degree (e.g., MA, MS, MEng, MEd, MSW, MBA). Enter MASTERS

Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DDS, DVM, LLB, JD) Enter either DOCTORATE or PROFESSIONAL:

WAS DECEDENT HISPANIC/ LATINO(A)/SPANISH/?

If not Hispanic/Latino(a)/Spanish, check No in box No. 14/15.

If Hispanic/Latino(a)/Spanish, check Yes in box No. 14/15 and enter specific origin.

No

Yes, Mexican, Mexican American, or Chicano

Yes, Central American

Yes, South American

Yes, Cuban

Yes, Puerto Rican

Yes, other Hispanic/Latino(a)/Spanish

Specify:

WHAT WAS DECEDENTS RACE OR ETHNICITY? (Check one or more races to indicate what the decedent considered himself or herself to be)

Enter text for up to 3 races in box No. 16

White

Black or African American

American Indian or Alaska Native (North, South, and Central American Indian) Specify Tribe(s):

Native Hawaiian

Guamanian

Samoan

Other Pacific IslanderSpecify:

Asian Indian

Cambodian

Chinese

Filipino

Hmong

Japanese

Korean

Laotian

Thai

Vietnamese

Other AsianSpecify:

OtherSpecify:

PRIVACY NOTIFICATION

Civil Code Section 1798.9 et seq. requires each state agency to provide notice to Individuals completing this form. The information is being requested by: DEPARTMENT OF HEALTH SERVICES, OFFICE OF VITAL RECORDS, MS 5103, P.O. Box 997410, Sacramento, CA 95899-7410. The information requested on this certificate is authorized and required by Divisions 7 and 102 of the Health and Safety Code, and related provisions within the Civil Code, Code of Civil Procedure, and Government Code.

The principal purpose for this record is:

1. To establish a permanent record that is legally recognized as prima facie evidence of the facts therein for each death occurring in the State of California.

2. To provide information, to health authorities and other qualified persons with a valid education or scientific interest, for demographic and epidemiological studies for health and social purposes.

3. To provide information to the National Center for Health Statistics for compiling national statistical reports, and to state and federal agencies for file clearance purposes.

4. To provide individuals with certified copies from the records to serve their personal needs, such as applying for social security or death benefits.

The record shall be open for examination during regularly scheduled office hours, except when access is specifically prohibited by statute or regulations.

LEGAL REQUIREMENTS FOR FILING CERTIFICATE OF DEATH

Each death shall be registered with the local registrar of births and deaths within eight calender days after death and prior to any disposition of the human remains.

The medical and health section data and the time of death shall be completed and attested to by the physician last in attendance, or his/her designee, provided such physician is legally authorized to certify and attest to these facts, or by the coroner in those cases in which he is required to complete the medical and health section data and certify and attest to these facts.

The medical and health section data and the physician or coroners certification shall be completed by the physician within 15 hours after the death, or by the coroner within three days after examination of the body.

Disclosure of Preneed Funeral Agreement

The funeral establishment, ____________________________________________________________, (funeral establishment name)

license number FD________, 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 Establishments 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 Date

____________________________________________ Print name of the survivor or responsible party

____________________________________________ ______________________________Signature of funeral establishment representative Date

____________________________________________ ______________________________Print name of funeral establishment representative Title The funeral establishment must:

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)

AUTHORIZATION TO ACCEPT OR DECLINE EMBALMING

TO: THE OMEGA SOCIETY

RE:

I,

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

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

Signed:

Executed this day of ,

, Relationship to Decedent:

.

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

The above statement of authorization and notification was read and/or provided to: , Relationship to decedent: , who did did not (check one) authorize embalming at the above named funeral establishment. Phone ( ) 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 , , at .

Funeral Establishment Representative (print name)

(Authorized Next of Kin), do do not (check one) request embalming

(Decedents Name)

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.

(Month) (Year)at

(City and State)

Funeral Establishment Representative (signature)

(Month) (Year) (City and State)

1577 NORTH MAIN STREET

ORANGE, CA 92867

OMEGA SOCIETY

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)

http:www.cfb.ca.gov

The Omega Society1577 North Main St., Orange, CA 92867

(714) 754-7781

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, Cemetery, 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 the Crematory and any applicable Federal, State, Local Laws, or Ordinances the undersigned hereby certifies, warrants and represents that I/We have the full legal right and authority to authorize and do hereby authorize the Crematory (hereafter the Crematory) to perform the cremation of the remains of;

Casket/Containers: The Crematory requires either a casket or alternative cremation container. All caskets and alternative containers must meet the following standards: 1) be composed of combustible materials suitable for cremation; 2) be able to be closed to provide a complete covering for human remains; 3) be resistant to leakage or spillage; 4) be sufficient for handling with ease; and 5) be able to provide protection for health and Safety of Crematory personal. The Crematory is authorized to inspect the casket or alternative container, including opening it if necessary. In the event there is leakage or damage, the Crematory may contact the Funeral Home directly for instructions. Metal, Plastic, Fiberglass Caskets or Cremation Containers will not be allowed to be cremated. The Crematory is authorized to remove and dispose of handles, ornaments and any other non-combustible items attached to the cremation container prior to cremation. I/We further authorize the Crematory to make disposition of any non-combustible items in any lawful manner it deems appropriate. These may include, but not limited to hinge, handles, latches, etc. In the event the urn or other container is insufficient 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 instructions on this form.

Pacemakers, 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 be removed prior to cremation. If the Crematory is not notified of these devices and implants, and not instructed to remove them, then the person(s) authorizing the cremation will be held responsible for any damages caused to the Crematory personnel or equipment by such devices or implants. By initialing this paragraph, I/We give permission to the, Crematory, Funeral Home, or staff to remove the surgical hardware as referenced above prior to cremation. The Funeral Home and or the Crematory are authorized to dispose of the devise(s) as deem appropriate.

Approximate Weight

(Hereafter The deceased/Decedent), and to arrange final disposition of the cremated remains as follows;[Decedents Usual Address]

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

Place of Final Disposition

I hereby DECLINE to View the Decedent at the Crematory;

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

Funeral Home handling the arrangements:(Hereafter the Funeral Home)

INITIAL

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

(ADDITIONAL CHARGE)

THE OMEGA SOCIETY

Casket or Cremation Container Selected /Urn SelectedALTERNATIVE CONTAINER PLASTIC UTILITY

YES NOPacemaker: (check one) INITIAL

Choose O

neCho

ose

One

INITIAL

The Cremation Process:The Human body burns with the casket, container, or other materials in the cremation chamber. Some bone fragments are not combustible at the incineration temperature and, as a result, remain in the cremation chamber. During the cremation, the contents of the chamber may be moved to facilitate incineration. The chamber is composed of ceramic or other material which disintegrates slightly during each cremation and the product of that disintegration is commingled with the cremated remains. Nearly all of the contents of the cremation chamber, consisting of the cremated remains disintegrated chamber material, and small amounts of residue from previous cremations, are removed together and crushed, pulverized, or ground to facilitate inurnment. Some residue remains in the cracks in uneven places of the chamber. Periodically, the accumulation of this residue is removed and inturred in a dedicated cemetery property or scattered at sea in accordance with State Laws. The acknowledgment 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 and silver, or jewelry (as well as any body prostheses or dental bridgework) that are left with the Decedent and are not removed from the casket or cremation container prior to cremation may be destroyed and become non-recoverable, or if not destroyed, they will be handled by the Crematory in accordance with the instructions on the instructions on the authorization. If you desire to save such items, the Authorizing Agent must make arrangements to remove any such possessions or valuables prior to cremation. After the cremated remains are removed from the cremation chamber, all non-combustible materials (insofar as possible), such as dental bridgework, body prosthesis, and materials from the casket or containers such as hinges, latches, etc., will be separated and removed from the human bone fragments by visible or magnetic selection. Unless specifically requested to return such items in writing, the Crematory is authorized to dispose of these materials with similar materials from other cremations in a non-recoverable manner, so that only the human bone fragments will remain. There may be small non-combustible material the operator may not visibly see and be placed into the urn with the human bone fragments. When the cremated remains are removed from the cremation chamber, the skeletal remains often contain recognizable bone 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 REMAINSI/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 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. I/We hereby authorize the Funeral Home to arrange for the disposition of the cremated remains of the Decedent as stated below: (Choose One)

Authorizing Agent: An Authorizing Agent is the person(s) having the right to control the disposition of the Decedent pursuant to Health and Safety Code Sec.7100.1.)Decedent, 2) An agent under power of attorney for Health care, 3) Spouse or Registered Domestic Partner. 4)Adult Children, 5) Parents, 6) Other surviving competent adult Kin. By signing this Authorization for Cremation and Disposition, I/We acknowledge and agree that I/We have read and understood every part of this authorization, including the fact that the process of cremation is irreversible, and I/We nevertheless desire that the Deceaseds remains be cremated in accordance with this authorization. I/We agree to indemnity, release and hold the Crematory, The Funeral Home, Their affiliates, Employees and assigns, harmless from any and all losses, damages, cost or expense, resulting from the Funeral Homes and Crematorys reliance on or performance 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 the Decedent to the Crematory.

INITIAL

INITIAL

INITIAL

INITIAL

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

SHIP TO:

RELEASE TO:

N/A

N/A

THE OMEGA SOCIETY FOR FINAL DISPOSITION

Printed Name:

Relationship:

Phone #:

Executed at on the day of, ,City and State Day Month Year

Deliver said cremated remains to:

SIGNATURE(To be signed by authorized next of kin, or self signed)

1. FREE OBITUARY (No Charge)Omega is pleased to provide you with a brief free obituary in the Orange County Register.Would you like us to place a free obituary announcement?

2. RETURN DATEDo the cremains need to be back OR at a location by a certain date?If so, by what date:

I understand that there may be an additional charge, depending on the immediacy of the turnaround time. I understand Omega will do its best to meet any deadline, but understand Omega cannot promise nor guarantee return dates, due to many outside factors including, but not limited to, Doctors, County Health

Departments, Crematory schedules, etc.

Are the cremains to be picked up?By whom:

Are the remains to be shipped?Ship to:

Are the cremains to be scattered at sea by Omega UN-witnessed by family?

3. WEIGHTDoes the decedent weigh 250 lbs. or more?Estimated weight:

4. PACEMAKERDoes the decedent have a pacemaker?

5. DEATH CERTIFICATESA certified copy of a death certificate is needed for any type of transfer of an asset where a survivor is receiving title or money. For example, certified death certificates are required for: bank accounts,brokerage accounts, stocks, bonds, CDs, Life Insurance policies, pension funds, IRAs, real estate, DMV and Social Secu-rity (for spouse and minor children only). Omega will order these for you from the County Health Department at the time the death certificate is filed there. Death Certificates will be mailed directly from the County Health Department and can take approximately up to 3 weeks from the ordering date to arrive.How many Certified Death Certificates would you like us to order?

Mail DCs to:

NOTE: Once death certificates have been ordered, additional certified copies should be ordered directly from the Health Department in the County where the death occurred. To prevent identity theft, death certiifcates may onlybe ordered by certain authorized persons. They include parent or legal guardian, child, grandparent, grandchild, sibling, spouse, domestic partner, or Durable Power of Attorney for Financial (without limitations). Orders may be made in person at the County Health Department upon presentation of a valid ID and Signature of a sworn statement attesting to your re-lationship. Or, orders may be made by mail by completing the appropriate Health Departments specific form and having it notarized by signing it before a sworn notary. Contact the local Health Department where the death occurred for further instructions

YES NO

YES NO

YES NO

YES NO

Phone:

(photo ID required)

YES NO (Add $75 removal fee)

(Name)(Address)

(Add $95 shipping)

Phone:

YES NO(Additional charges for weight of 250 lbs. or more. Weight will be verified.)

(Name)(Address)

(Add $21 for each certified copy)

(day of week) (month) (day) (year), , ,

OMEGA SOCIETY ADDITIONAL INFORMATION

I have read & understand the above: Date:

INITIAL

YES NO

O r a n g e C o u n t y

RegisterRETURN TO:

OMEGA SOCIETYONLY 2 LINES FREE

(WE WILL EDIT TO FIT)

The Orange County Register will print the following information. There is no charge to you. Notices appear as space is available. We CANNOT guarantee the date of publication.

Fore more detailed PAID Eulogies, call (714) 796-4973.

Name of deceased:

Date of death:

Lived in which city:

Age:

You may also place a longer obituary yourself, in addition to this Free Announcement. If you would

like a separate, more detailed, PAID obituary, with a specific publication date, please contact the

OC Register directly.

Name and phone number of mortuary: The Omega Society - (714) 754-7781

625 North Grand Avenue, Santa Ana, California 92701 (714) 835-1234

TELEPHONE NUMBER

2. SOCIAL SECURITY NUMBER

- - 5. Check (x) whether the deceased was

FOR SOCIAL SECURITY USE ONLY - DO NOT WRITE IN THIS SPACE

3. DATE OF DEATH

Form SSA-721 (5-2005) ef (8-2008) Use 1-2004 edition until supply is exhausted

DATE

FemaleMale

ZIP CODE

-

TELEPHONE NUMBER (if Available)( ) -

area code

1. NAME OF DECEASED

STATECITY

area code

DO Processed (Date)

NAME AND ADDRESS OF FUNERAL DIRECTOR OR FIRM SIGNATURE OF FUNERAL DIRECTOR OR AUTHORIZEDREPRESENTATIVE

I hereby certify that I am an authorized funeral director and prepared for final disposition the body of the person named above. I understandthis statement may be used in connection with an application for Social Security benefits. I declare under penalty of perjury that I haveexamined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of myknowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causessomeone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.

PRIVACY ACT/PAPERWORK ACT NOTICE: The information on this form is authorized by Section 404.715 and 404.720 of the FederalRegulations (20 CFR 404.715 and 404.720). While your response is voluntary, we need your assistance to make an accurate and timelydetermination concerning the death of the individual named above, and to determine if there are survivors who may be eligible for SocialSecurity benefits.

We may also use the information you give us when we match records by computer. Matching programs compare our records with those of otherFederal, State or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid bythe Federal government. The law allows us to do this even if you do not agree to it.

Explanations about these and other reasons why information you provide us may be used or given out are available in Social Security Offices. If youwant to learn more about this, contact any Social Security Office.

Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S.C. 3507, as amended by Section 2 of thePaperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget controlnumber. We estimate that it will take about 3.5 minutes to read the instructions, gather the facts, and answer the questions. SEND THECOMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in yourtelephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimateabove to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not thecompleted form.

STATEMENT OF DEATH BY FUNERAL DIRECTORNAME OF DECEASED SOCIAL SECURITY NUMBER

- -

Form ApprovedOMB No. 0960-0142SOCIAL SECURITY ADMINISTRATION

4. DATE OF BIRTH (if known)

6. NAME OF WIDOW OR WIDOWER (if known)

7. ADDRESS (No. and Street, P.O. Box) OF WIDOW OR WIDOWER (if known)

Please complete the items below, and return theform in the enclosed addressed, postage paidenvelope. Your assistance and cooperation areappreciated.

( ) -

FOR SSA USE ONLY

NAME of DECEDENT:Basic Services of Funeral Director and Staff & OverheadTransportation/Removal from Place of DeathPermit Fee (Health Department Charge)Certified Copies of Death Certificate ( _______ @ $ each)State Crematory TaxOther Services/Additional or Optional Charges:

Transportation beyond Removal or RadiusShipping of Cremated Remains within Continental USPacemaker RemovalUrn (Upgrade from Plastic Provided)JewelryYacht Charter for Private Witnessed Sea ScatteringWhite Dove ReleaseWeight Special Handling (250 lbs. or More)Viewing/Informal Identification of Deceased at CrematoryWitnessing of Cremation (Insertion Only)Rush/Priority ServiceCoroners ChargesNew Permit: Change Disposition or ReplaceScattering at Sea Only (Without Cremation)EmbalmingEmbalming FacilityTransport To & From Embalming FacilityDress/Cosmetology/Hair/CasketingTransportation to Location for Viewing & StandbyTransportation to Memorial/Funeral/Cemetery Service & StandbyFuneral CoachFlowersCasket: Cloth Covered Pressed Wood/Steel/WoodVault/Outer Burial ContainerHeadstone/MarkerMinister/ClergyOther:

TOTAL PAIDBALANCE DUE

SIGNATURE Date(To be signed by authorized next of kin, or self signed)

THE OMEGA SOCIETY FD12801577 North Main St., Orange, CA 92867 * 714-754-7781 * FAX 714-754-7103

Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items, we will explain the reasons in writing below.

FOR MORE INFORMATION ON FUNERAL MATTERS, CONTACT: DEPARTMENT OF CONSUMER AFFAIRS, CEME-TERY & FUNERAL BUREAU, 1625 NORTH MARKET BLVD., SUITE S-208, SACRAMENTO, CA 95834, 916-574-7870

$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$

$$$

CREMATION BURIAL

TOTAL COST: DUE PROMPTLY

(A SERVICE CHARGE OF 1 1/2% PER MONTH (18% PER ANNUM) WILL BE ADDED TO PAST DUE AMOUNTS.)

If any legal, or crematory requirement has required the purchase of any of the items listed above, we will explain the requirement below:

PAYMENT IS DUE PROMPTLY. PLEASE MAIL A CHECK OR MAKE CREDIT CARD* ARRANGEMENTS WITHIN 24 HOURS. THANK YOU!

* 2.5% administration fee on all credit and debit card payments, VISA and MasterCard only

AKA_Middle: AKA_Last: Dec_Sex: Dec_Race: Dec_Street: Dec_Apt: Dec_State: Dec_Zip: Dec_County: Dec_Home_PhoneArea: Dec_Home_Phone_7: Dec_Yrs_County: Dec_Children: Dec_Birthplace: Dec_Ed: Dec_Father_First: Dec_Father_Middle: Dec_Father_Last: AKA_First: Dec_Mother_First: Dec_Mother_Middle: Dec_Mother_Last: Spouse_First: Spouse_Middle: Spouse_Last: Marital: Dec_Occupation: Dec_Yrs_Wrk: Dec_Industry: US_Vet: NoK1_Name: NoK1_Relation: NoK1_Street: NoK1_Apt: NoK1_City: NoK1_State: NoK1_Zip: NoK1_Home_PhoneArea: NoK1_Home_Phone_7: NoK1_Cell_PhoneArea: NoK1_Cell_Phone_7: NoK2_Name: NoK2_Relation: NoK2_Street: NoK2_Apt: NoK2_City: NoK2_State: NoK2_Zip: NoK2_Home_PhoneArea: NoK2_Home_Phone_7: NoK2_Cell_PhoneArea: NoK2_Cell_Phone_7: NoK1_Email: NoK2_Email: Dec_Full: Signature_Date: Sea_Type: Scatter_County: Dispo: Return_who: PU_Ship: Return_Phone: Cem_Name: Cem_Street: Cem_Phone: Cem_City: Cem_State: Cem_County: Cem_Zip: Pacemaker: Signer_Name: Signer_Relation: Race: 0-11th_Choices: [0]Education: Box14/15: Indian_Specify: PI_Specify: 14/15_Specify: Doc/Prof: [Doctorate]Asian_Specify: Other_Specify: Fun_Home: The Omega Society FD_Num: 1280Preneed: Text89: Janet de MichaelisFun_Rep_Title: PresidentDOES = Pre-Registered or Pre-Paid: DOES NOT = NOT Pre-Registered nor Pre-Paid: Embalm: Name of Funeral Establishment and Telephone Number: The Omega Society (714) 754-7781Name of Crematory and Telephone Number: The Omega Society (714) 754-7781Manner, Location and Other Details of Disposition: Manner, Location and Other Details of Disposition line 2 of 4: Manner, Location and other details of Disposition line 3 of 4: Manner, Location and other details of Disposition line 4 of 4: Name of persons with the legal right to control disposition line 1 of 3: Name of persons with the legal right to control disposition line 2 of 3: Name of persons with the legal right to control disposition line 3 of 3: 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: Name of persons contracting for cremation services line 1 of 2: Name of persons contracting for cremation services line 2 of 2: Janet_Sig: License number if a Funeral Director: 486Dec_Father_Birthplace: Dec_Mother_Birthplace: Dec_First: Dec_Middle: Dec_Last: Decedents_addy: Final_Dispo: Executed_City: Executed_State: Executed_Day: Executed_Month: Executed_Year: Signer_Phone: Free_Obit: Return_Date: Need_Back_Day_Week: Need_Back_Month: Need_Back_Day: Need_Back_Year: Pickup: PU_Phone: PU_By: Ship: Ship_Name: Ship_Addy1: Ship_Phone: Sea_Unwitnessed: Weight: Approx_Weight: DC_Name: DC_Addy1: Ship_Addy2: Dec_Age: Dec_City: Dec_SS_Num: Dec_DoD: Dec_DoB: Sex: Wid_Name: Wid_Address: Wid_City: Wid_State: Wid_Zip: Wid_Phone: Text2: The Omega Society 1577 N. Main St.Orange, CA 92867Omega_Area_Code: 714Omega_Phone_Pref: 754Omega_Phone_End: 7781Cost_Basic: Cost_Transport: Cost_Permit: Num_Certified: Certifieds_Each: 21Cost_Certified: 0Cost_State_Tax: Cost_Misc: Cost_Added_Transport: Cost_shipping: Cost_Pacemaker: Cost_Urn: Cost_Jewelry: Cost_Charter: Cost_Dove: Cost_Weight: Cost_ID_View: Cost_Witness: Cost_Rush: Cost_Coroner: Cost_Permit_Change: Cost_Sea: Cost_Embalming: Cost_Emb_Facility: Cost_Emb_Transport: Cost_Dressing: Cost_Viewing_Transport: Cost_Service_Transport: Cost_Coach: Cost_Flowers: Cost_Casket: Cost_Vault: Cost_Marker: Cost_Clergy: Other_Charges: Cost_Other: Total_Cost: 0Total_Paid: Total_Due: 0View_type: Cremation_vs_Burial: DC_Addy2: Race_white: Race_black: Race_indian: Race_hawaiian: Race_Guamanian: Race_Samoan: Race_PI: Race_Asian_Indian: Race_Cambodian: Race_Chinese: Race_Filipino: Race_Japanese: Race_Korean: Race_Laotian: Race_Thai: Race_Vietnamese: Race_Other_Asian: Race_Other: Astric: Total_Paid_Info: Num_Certified_A: