CERTIFICATE OF DEATH
STATE OF CALIFORNIA
USE BLACK INK ONLY / NO ERASURES, WHITOUTS OR ALTERATIONS
VS-11 (REV 1/03
1. NAME OF DECEDENT – FIRST (Given) 2. MIDDLE 3. LAST (Family)
AKA ALSO KNOWN AS – Include full AKA 4. DATE OF BIRTH mm/dd/ccyy 5. DATE OF DEATH mm/dd/ccyy 6. SEX
7.BIRTH STATE/FOREIGN COUNTRY 8. SOCIAL SECURITY NO. 9. EVER IN U.S. ARMED FORCES? 10. MARITAL STATUS*
11. EDUCATION – Highest Level/Degree 12/13 WAS DECEDENT: SPANISH / HISPANIC / LATINO? 14. DECEDENT’S RACE — Up to 3 races may be listed (see worksheet on back)
15. USUAL OCCUPATION – TYPE OF WORK FOR MOST LIFE. DO NOT USED RETIRED 16. KIND OF BUSINESS OR INDUSTRY (e.g., grocery store, road construction, employment agency, etc.) 17. YEARS IN OCCUPATION
18. DECEDENTS RESIDENCE: (Street and number or location)
19. CITY 20. COUNTY/PROVINCE 21. ZIP CODE 22. YEARS IN COUNTY 23. STATE/FOREIGN COUNTRY
24. INFORMANT’S NAME, RELATIONSHIP 25. INFORMANT’S MAILING ADDRESS (Street and number or rural route, city or town, state, ZIP)
26. NAME OF SURVIVING SPOUSE – FIRST 27. MIDDLE 28. LAST (Maiden Name)
29. NAME OF FATHER – FIRST 30. MIDDLE 31. LAST 32. BIRTH STATE or COUNTRY
33. NAME OF MOTHER – FIRST 34. MIDDLE 35. LAST (Maiden Name) 36. BIRTH STATE or COUNTRY
37. PLACE OF FINAL DISPOSITION (Full Address Required)
(Location Required: name of person’s residence and complete address, or name of cemetery and address, or scatter at sea. Please state one.
38. TYPE OF DISPOSITION 39. EMBALMING
40. NAMEOF FUNERAL ESTABLISHMENT 43. LICENSE NUMBER 44. DATE mm/dd/ccyy
41. PLACE OF DEATH 42. IF HOSPITAL, SPECIFY ONE: 43. IF OTHER THAN A HOSPITAL, SPECIFY ONE
44. COUNTY 45. FACILITY ADDRESS OR LOCATION WHERE FOUND (Street and number or location) 46. CITY
Are you planning a Funeral Service or a Memorial Service? YES NO Where? _______________________ When? _______________________
Informant Contact/Phone Number(s) Home _________________________________________ Cell ____________________________________________
Email (Required) _________________________________________ Cell ____________________________________________
City of Birth _____________________________
_____________________________________ You understand that in the cremation process, we allow the legal next of kin to communicate and get an
update if needed. The Legal next of kin, and only the legal next of kin as, so stated by law in the Cemetery and Funeral Bureau, Health and Safety codes,
section 7100, that the legal next of kin and/or the legal informant will only be given information. As the legal next of kin, and/or legal informant, understand
and agree that only one person can and will pick up the cremated remains, and/or personal belongings. You as the legal next of kin, and/or legal informant
authorize the following one (1) person _____________________________________ to pick up cremated remains. If your request is for the Funeral Home
to deliver said cremated remains, you select this option, you authorize Chapman Funeral Homes to deliver to _____________________________________ ,
by the date________________.You understand that additional charges may be required, and must be paid in full before requested delivery date. This will
also apply to any shipping costs.
SIGNED: ______________________________________________________________________________________________________________________
DEATH CERTIFICATE REQUEST
#OF DEATH CERTIFICATES _______________
MAIL TO: _____________________________________________________ ADDRESS: ____________________________________________________
CITY: ________________________________________________ STATE: _________ ZIP: __________ TELEPHONE: _______________________
IP
Residence YES
HospiceER/OP
Cemetery NO
Nursing
Home/TLC
DOA
Scatter at Sea
Decedent’s
Home
Other
YES ______________________________________________________ NO
YES NO UNK
DECEDENT’S PERSONAL DATAUSUAL
RESIDENCE
INFOR
MANT
SPOUSE AND PARENT
INFORMATION
PLACE OF
DEATH
DISPOSITION/
*SINGLE IS NOT ACCEPTED
DOCTOR: _______________________________________________________________________________ PHONE: _____________________________
ADDRESS: ______________________________________________________________________________ FAX: ________________________________
TIME AVAILABLE: _____________________________________________________________________________________________________________
X
