THE OMEGA SOCIETY ® FAX: 714-754-7103

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 FOR BURIAL
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 bury 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:
CEMETERY INTERMENT:
Complete Cemetery Name:
Cemetery Address (Street):
City
Phone:
State
County
Zip
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
®
MELROSE ABBEY MORTUARY
1577 NORTH MAIN STREET
2303 SOUTH MANCHESTER AVE.
ORANGE, CA 92867
ANAHEIM, CA 92802
(Funeral Establishment Name & Address)
(Embalming Facility Name & Address)
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
.
To Be Completed by Funeral Establishment if Authorization to Embalm and Notification to Transport Is
Obtained Orally (by Telephone):
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:
,
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
.
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. BURIAL DATE
Is the decedent to be buried on a certain date?
If so, by what date:
,
(day of week)
(month)
,
YES
NO
,
(day)
(year)
Time:
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 HealthDepartments, etc.
INITIAL
3. VIEWING/FUNERAL SERVICE
Are the remains going to a location for a viewing or service?
Deliver to:
YES
NO
(Name)
(Address)
Phone:
Time:
Date of Viewing/Service
Special Instructions:
4. 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:
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 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 certificates 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, CEME
TERY & 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