DECEDENT'S LEGAL NAME: FIRST NAME MIDDLE LAST

AKA: FIRST, MIDDLE, LAST DATE OF BIRTH AGE SEX

BIRTH STATE (COUNTRY, IF NOT US) SOCIAL SECURITY NUMBER VETERAN? Y/N MARITAL STATUS

DATE OF DEATH HIGHEST LEVEL OF EDUCATION HISPANIC DESCENT? Y/N DECEDENT'S RACE

USUAL OCCUPATION (One Only. Retired/Disabled unaceptable) KIND OF BUSINESS/INDUSTRY YRS IN OCCUPATION

DECEDENT’S ADDRESS, CITY, STATE, ZIP CODE

SURVIVING SPOUSE'S FULL NAME (FIRST, MIDDLE, LAST (BIRTH/MAIDEN LAST NAME, IF FEMALE)

FATHER'S FIRST NAME FATHER'S MIDDLE NAME FATHER'S LAST NAME

MOTHER'S FIRST NAME MOTHER'S MIDDLE NAME MOTHER'S MAIDEN NAME (AT BIRTH)

PLACE OF DISPOSITION: NAME, ADDRESS, CITY, STATE, ZIP (FINAL RESTING PLACE, EXAMPLE: RESIDENCE, CEMETERY NAME, OR COUNTY OF SEA SCATTERING)

I HEREBY ALLOW THE OMEGA SOCIETY TO PLACE THE ABOVE INFORMATION ON THE DEATH CERTIFICATE (To be signed by authorized Next of Kin, or self-signed)

DATE

PRIMARY TELEPHONE ALTERNATE PHONE EMAIL ADDRESS

COUNTY YRS IN COUNTY

# OF LIVING CHILDREN

PRINT NAME (Next of Kin's full name) RELATIONSHIP

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

Phone:714-754-7781Fax: 714-754-7103

THE OMEGA SOCIETY FD1280

**Please compete 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.

REGISTRATION APPLICATION

FOR MORE INFORMATION ON FUNERAL, CEMETERY AND CREMATION MATTERS, CONTACT: DEPARTMENT OF COMSUMER AFFAIRS, CEMETERY AND FUNERAL BUREAU, 1625 NORTH MARKET BLVD., SUITE S-208, SACRAMENTO, CA 95834, 916-574-7870

PRIMARY TELEPHONE ALTERNATE PHONE EMAIL ADDRESS

SECOND NEXT OF KIN NAME RELATIONSHIP

®

NEXT OF KIN'S FULL ADDRESS

BIRTHPLACE (State Only, Country if Not US)

BIRTHPLACE (State Only, Country if NotUS)

Married/Nvr Married/Widowed/Div/SRDP

1

AUTHORIZATION FOR BURIAL

AUTHORIZATION TO RELEASE This is my authorization to release the remains of:

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 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:

Complete Cemetery Name:

Cemetery Address (Street):

City State County Zip

Phone:

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.

CEMETERY INTERMENT:

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

to THE OMEGA SOCIETY® 1577 N Main St. Orange, CA 92867

Phone: 714-754-7781 Fax: 714-754-7103

If Deceased, Date of Death: _____________ Location of Decedent: _______________________

2

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 highestyear 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

Bachelor’s degree (e.g., BA, AB, BS). Enter BACHELOR’S

Master’s degree (e.g., MA, MS, MEng, MEd, MSW, MBA). Enter MASTER’S

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

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 DECEDENT’S 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 ofCalifornia.

2. To provide information, to health authorities and other qualified persons with a valid education or scientific interest, for demographic and epidemiologicalstudies 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 fileclearance 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.

3

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 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

____________________________________________ ______________________________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)

4

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:

Signed:

Executed this day of ,

, Relationship to Decedent:

.

, 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)

OMEGA SOCIETY®

1577 NORTH MAIN STREET

ORANGE, CA 92867

, do do not (check one) request embalming.

(Decedent’s 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)

SCOTT MCAULAY FAMILYNEW OPTIONS FUNERAL SERVICE

1100 S. RAYMOND AVE. #C

FULLERTON, CA 92831

Janet de Michaelis

(Only if washed or embalmed)

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

Orange, CA

FOR OMEGA SOCIETY USE ONLYThis section is to be completed by the funeral establishment if authorization to accept or decline embalming is obtained orally.

The above statement regarding embalming and storage was read and/or provided to:

5

12-AUTH (rev. 11/14)

1. FREE OBITUARY (No Charge)

Is the decedent to be buried on 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 HealthDepartments, etc.

3. VIEWING/FUNERAL SERVICEAre the remains going to a location for a viewing or service?Deliver to:

Date of Viewing/Service

Special Instructions:

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

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: 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). Death Certificates arrive by mail in 2-3 weeks (OC), up to 4 weeks (other counties), mailed directly from the County Health Department (not from the Omega Society office) How many Certified Death Certificates would you like us to order?

Mail DC’s 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 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 re-lationship. 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. You can also order Death Certificates online at www.vitalchek.com/death-certificates

YES NO

The OC Register no longer provides free obituaries. If you would like to place a paid obituary in The Register, please call them directly at 714-796-4973. You will be billed directly by the Register on a per line basis. Omega Society families receive preferred pricing. 2. BURIAL DATE

YES NO

YES NO

Phone:

(Additional charges for weight of 250 lbs. or more. Weight will be verified.)

(Name)

(Address)

(Add $21 for each certified copy)

(Name)

(Address)

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

OMEGA SOCIETY ADDITIONAL INFORMATION

I have read & understand the above: Date:

INITIAL

Time:

Time:

6

NAME of DECEDENT:Basic Services of Funeral Director and Staff & Overhead Transportation/Removal from Place of DeathPermit Fee (Health Department Charge)Certified Copies of Death Certificate ( _______ @ $21 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 ServiceCoroner’s 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, CEMETERY & 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 MAKECREDIT CARD* ARRANGEMENTS WITHIN 24 HOURS. THANK YOU!

* 3.5% administration fee on all credit and debit card payments, VISA, MasterCard, Discover; 3.5% Amex

8