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1577 North Main St.
Orange, CA 92867
Phone:
FAX:
www.omegasociety.com
714-754-7781
714-754-7103
THE OMEGA SOCIETY®
REGISTRATION 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
(First)
(Middle)
(Last)
Legal AKA (if applicable)
Sex
Race
Apt. #
Street
City
Zip
State
Phone (H) (
County
Social Security #
)
Date of Birth
Age
Years Resided in County
# Living Children
Birthplace (State Only, or Country if not US)
Father’s Full Name
(First)
Mother’s Full Maiden Name
Surviving Spouse’s Full Name
(Maiden Name, if female)
Marital Status
(Current):
Highest Education
Married
(First)
(Middle)
Decedent’s Occupation
Birthplace
(Maiden Name)
(First)
Never Married
Birthplace
(Last)
(Middle)
(Middle)
Widowed
State Only
State Only
(Last or Maiden Name, if female)
Divorced
State Registered Domestic Partner
# Years in Profession
(prior to retirement)
Type of Industry/Business
Veteran: Yes
No
(For burial at a veterans cemetery, please provide a copy of DD-214 Honorable Discharge Form)
Immediate Next of Kin
Relationship
(Used on death certificate)
Street
Apt. #
City
Phone (H)(
State
)
(Email)
Second Next of Kin
(Cell)(
Zip
)
Relationship
Street
Apt. #
City
Phone (H)(
State
)
(Email)
(Cell)(
Zip
)
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
Date
SIGNATURE
(To be signed by authorized next of kin, or self signed)
AUTHORIZATION TO RELEASE
This is my authorization to release the remains of:
(Please print the full name of the person for whom arrangements are being made.)
to THE OMEGA SOCIETY®
1577 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)
Relationship
Print Name
AUTHORIZATION TO CREMATE
The undersigned hereby requests and authorizes THE OMEGA SOCIETY® or it’s assigns, in accordance
with and subject to it’s rules and regulations, to cremate the remains of:
(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 it’s 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:
Unwitnessed Sea
(by Omega, no family present)
If at Sea, By Family: To be scattered off the coast of
Private Sea Charter
(by Omega, family to witness)
County
At Sea, by Family
(Family to scatter themselves)
RETURN TO FAMILY: (for Special Disposition as provided in Health and Safety Code)
Return to whom:
To be picked up
Omega to ship (additional charge)
Phone:
CEMETERY INURNMENT: Complete Cemetery Name:
Cemetery Address (Street):
City
To be picked up
Omega to ship (additional charge)
I certify the deceased
does
State
Phone:
County
Zip
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.
SIGNATURE
Print Name
(To be signed by authorized next of kin, or self signed)
Date
Relationship
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: 0
12th grade, but no diploma.
Enter 12 ND
High school graduate or
GED completed. Enter
HS GRADUATE
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.
Enter text for up to 3 races in box No. 16
White
Black or African American
No
American Indian or Alaska Native
(North, South, and Central American Indian)
Specify Tribe(s):
Yes, Mexican, Mexican American,
or Chicano
Native Hawaiian
Yes, Central American
Guamanian
Samoan
Yes, South American
Some college credit, but no
degree. Enter
SOME COLLEGE
Yes, Cuban
Associate degree (e.g., AA,
AS). Enter ASSOCIATE
Yes, other Hispanic/Latino(a)/Spanish
Bachelor’s degree (e.g., BA,
AB, BS). Enter BACHELOR’S
WHAT WAS DECEDENT’S RACE OR ETHNICITY? (Check
one or more races to indicate what the decedent
considered himself or herself to be)
Other Pacific Islander
Specify:
Asian Indian
Yes, Puerto Rican
Cambodian
Specify:
Chinese
Filipino
Hmong
Master’s degree (e.g., MA,
MS, MEng, MEd, MSW, MBA).
Enter MASTER’S
Japanese
Korean
Doctorate (e.g., PhD, EdD)
or Professional degree
(e.g., MD, DDS, DVM, LLB,
JD) Enter either
DOCTORATE or
PROFESSIONAL:
Laotian
Thai
Vietnamese
Other Asian
Specify:
Doctorate
Other
Specify:
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 coroner’s 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 Omega Society ®
The funeral establishment, ____________________________________________________________,
*
(funeral establishment name)
*
1280 DOES ____, DOES NOT ____ (check one) have a preneed arrangement, as
license number FD________,
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
______________________________
Date
____________________________________________
Print name of the survivor or responsible party
____________________________________________
______________________________
Janet de Michaelis
____________________________________________
President
______________________________
Signature of funeral establishment representative
Print name of funeral establishment representative
Date
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 the
disclosure statement was made, whichever comes first.
21F1 (10/03)
DOES = Pre-Registered or Pre-Paid
DOES NOT = NOT Pre-Registered nor Pre-Paid
AUTHORIZATION FOR DISPOSITION WITH OR
WITHOUT EMBALMING
TO: THE OMEGA SOCIETY®
RE:
(Decedent’s Name)
I,
, do
(Authorized Next of Kin)
do not
(check one)
request embalming, which I understand 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 understand that for storage or embalming purposes the decedent may be transported to the
following licensed funeral establishment:
OMEGA SOCIETY®
1577 NORTH MAIN STREET
ORANGE, CA 92867
then returned for funeral services. I understand I may be charged an additional fee for transport.
The undersigned hereby represents that he/she has the legal right to control disposition of the
remains of the decedent.
Signed:
Executed this
, Relationship
day of
,
, at City
, State
.
The above statement of authorization and notification was read to
Relationship
, who did
did not
(check one) authorize embalming at the
above named funeral establishment. City
, State
,
Phone (
) Date and time authorization granted:
,
To Be Completed by Funeral Establishment if Authorization to Embalm and Notification to Transport Is
Obtained Orally (by Telephone):
Signature of funeral establishment representative accepting authorization.
I declare under penalty of perjury that the foregoing is true and correct.
Executed this
signature
day of
,
, at City
, State
.
DECLARATION FOR DISPOSITION OF CREMATED REMAINS I/We hereby declare (my remains) or (the remains of)
the possession of
Name of Person arrangements are for
The Omega Society ® (714) 754-7781
Name of Funeral Establishment and Telephone Number
The Omega Society ® (714) 754-7781
Name of Crematory and Telephone Number
manner (Note 1):
, will be cremated by
and shall be disposed of in the following
Manner, Location and Other Details of Disposition
Name of person(s) with the legal right to control disposition (Note 2):
Signed
Signed
Signed
Signed
in
Attach additional pages if necessary
Date
Person(s) with legal right to control disposition to Self, if pre-arranging
Date
Person(s) with legal right to control disposition
Date
Person(s) with legal right to control disposition
Date
Person(s) with legal right to control disposition
Name of person(s) contracting for cremation services:
Signed
Signed
Person(s) contracting for cremation services
Funeral Director, Employee, or Agent for Funeral Establishment
Date
Lic. #
486
If a Funeral Director
Date
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) The Omega Society®
1577 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;
[FIRST NAME]
[MIDDLE NAME]
[LAST NAME]
Approximate Weight
[Decedents Usual Address]
(Hereafter The “deceased/Decedent”), and to arrange final disposition of the cremated remains as follows;
I hereby DECLINE to View the Decedent at the Crematory; INITIAL
I REQUEST a Viewing of the Decedent at the Crematory; Date/Time
/
; INITIAL
(ADDITIONAL CHARGE)
ID Viewing
or
Witness
the insertion into the cremation chamber (Check One)
THE OMEGA SOCIETY®
Funeral Home handling the arrangements:
(Hereafter the Funeral Home)
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.
Casket or Cremation Container Selected ALTERNATIVE CONTAINER /Urn Selected
PLASTIC UTILITY
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.
Pacemaker:
YES
NO
(check one) INITIAL
Choose One
Choose One
Place of Final Disposition
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.
INITIAL
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 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)
INITIAL
N/A
Deliver said cremated remains to:
INITIAL
N/A
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:
INITIAL
RELEASE TO:
THE OMEGA SOCIETY® FOR FINAL DISPOSITION
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 Deceased’s 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 Home’s and Crematory’s 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.
Executed at
on the
City and State
SIGNATURE
Printed Name:
day of,
Month
Day
(To be signed by authorized next of kin, or self signed)
Relationship:
Phone #:
,
Year
OMEGA SOCIETY® ADDITIONAL INFORMATION
1. FREE OBITUARY (No Charge)(Orange County Residents only)
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?
YES
NO
2. RETURN DATE
Do the cremains need to be back OR at a location by a certain date?
If so, by what date:
,
,
,
(day of week)
(month)
(day)
YES
NO
(year)
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.
INITIAL
Are the cremains to be picked up?
By whom:
Are the remains to be shipped?
Ship to:
YES
NO
Phone:
(photo ID required)
YES
NO (Add $95 shipping)
(Name)
(Address)
Phone:
Are the cremains to be scattered at sea by Omega UN-witnessed by family?
YES
NO
3. WEIGHT
Does the decedent weigh 250 lbs. or more?
YES
NO
(Additional charges for weight of 250 lbs. or more. Weight will be verified.)
Estimated weight:
4. PACEMAKER
Does the decedent have a pacemaker?
YES
NO (Add $75 removal fee)
5. DEATH CERTIFICATES
A 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, CD’s, Life Insurance policies, pension funds, IRAs, real estate, DMV and Social Security (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?
(Add $21 for each certified copy)
Mail DC’s to:
(Name)
(Address)
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 only
be 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 relationship. Or, orders may be made by mail by completing the appropriate Health Department’s 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
I have read & understand the above:
Date:
ONLY 2 LINES FREE
(WE WILL EDIT TO FIT)
Register
Orange County
RETURN TO:
OMEGA SOCIETY
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:
Age:
Date of death:
Lived in which city:
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.
This is available for
Orange County Residents only.
Name and phone number of mortuary:
The Omega Society - (714) 754-7781
625 North Grand Avenue, Santa Ana, California 92701 (714) 835-1234
Form Approved
OMB No. 0960-0142
SOCIAL SECURITY ADMINISTRATION
STATEMENT OF DEATH BY FUNERAL DIRECTOR
SOCIAL SECURITY NUMBER
NAME OF DECEASED
-
-
FOR SSA USE ONLY
Please complete the items below, and return the
form in the enclosed addressed, postage paid
envelope. Your assistance and cooperation are
appreciated.
PRIVACY ACT/PAPERWORK ACT NOTICE: The information on this form is authorized by Section 404.715 and 404.720 of the Federal
Regulations (20 CFR 404.715 and 404.720).
While your response is voluntary, we need your assistance to make an accurate and timely
determination concerning the death of the individual named above, and to determine if there are survivors who may be eligible for Social
Security benefits.
We may also use the information you give us when we match records by computer. Matching programs compare our records with those of other
Federal, State or local government agencies. Many agencies may use matching programs to find or prove that a person qualifies for benefits paid by
the 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 you
want 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 the
Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control
number. We estimate that it will take about 3.5 minutes to read the instructions, gather the facts, and answer the questions. SEND THE
COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U. S. Government agencies in your
telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate
above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the
completed form.
2. SOCIAL SECURITY NUMBER
1. NAME OF DECEASED
3. DATE OF DEATH
-
5. Check (x) whether the deceased was
Male
Female
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)
STATE
CITY
ZIP CODE
TELEPHONE NUMBER (if Available)
-
(
)
-
area code
I hereby certify that I am an authorized funeral director and prepared for final disposition the body of the person named above. I understand
this statement may be used in connection with an application for Social Security benefits. I declare under penalty of perjury that I have
examined all the information on this form, and on any accompanying statements or forms, and it is true and correct to the best of my
knowledge. I understand that anyone who knowingly gives a false or misleading statement about a material fact in this information, or causes
someone else to do so, commits a crime and may be sent to prison, or may face other penalties, or both.
NAME AND ADDRESS OF FUNERAL DIRECTOR OR FIRM
The Omega Society ®
1577 N. Main St.
Orange, CA 92867
SIGNATURE OF FUNERAL DIRECTOR OR AUTHORIZED
REPRESENTATIVE
TELEPHONE NUMBER
( 714 ) 754 - 7781
area code
FOR SOCIAL SECURITY USE ONLY - DO NOT WRITE IN THIS SPACE
DO Processed (Date)
Form SSA-721 (5-2005) ef (8-2008) Use 1-2004 edition until supply is exhausted
DATE
THE OMEGA SOCIETY® FD1280
1577 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 reasins in writing below.
FOR MORE INFORMATION ON FUNERAL MATTERS, CONTACT: DEPARTMENT OF CONSUMER AFFAIRS, CEMETERY & FUNERAL BUREAU, 1625 NORTH MARKET BLVD., SUITE S-208, SACRAMENTO, CA 95834, 916-574-7870
NAME of DECEDENT:
Basic Services of Funeral Director and Staff & Overhead
Transportation/Removal from Place of Death
Permit Fee (Health Department Charge)
Certified Copies of Death Certificate ( _______ @ $ 21 each)
State Crematory Tax
Other Services/Additional or Optional Charges:
Transportation beyond Removal or Radius
Shipping of Cremated Remains within Continental US
Pacemaker Removal
Urn (Upgrade from Plastic Provided)
Jewelry
Yacht Charter for Private Witnessed Sea Scattering
White Dove Release
Weight Special Handling (250 lbs. or More)
Viewing/Informal Identification of Deceased at Crematory
Witnessing of Cremation (Insertion Only)
Rush/Priority Service
Coroner’s Charges
New Permit: Change Disposition or Replace
Scattering at Sea Only (Without Cremation)
Embalming
Embalming Facility
Transport To & From Embalming Facility
Dress/Cosmetology/Hair/Casketing
Transportation to Location for Viewing & Standby
Transportation to Memorial/Funeral/Cemetery Service & Standby
Funeral Coach
Flowers
Casket: Cloth Covered Pressed Wood/Steel/Wood
Vault/Outer Burial Container
Headstone/Marker
Minister/Clergy
Other:
TOTAL PAID
BALANCE DUE
CREMATION
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
TOTAL COST: DUE PROMPTLY $
$
$
BURIAL
0
0.00
0.00
(A SERVICE CHARGE OF 1 1/2% PER MONTH (18% PER ANNUM) WILL BE ADDED TO PAST DUE AMOUNTS.)
SIGNATURE
(To be signed by authorized next of kin, or self signed)
Date
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!
* 3.5% administration fee on all credit card payments