VITAL STATISTICS INFORMATIONREQUIRED BY THE STATE OF CALIFORNIA

TO COMPLETE THE CERTIFICATE OF DEATH.

FORM FIELDS WILL CONTAIN GAP(S).

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 OF LIFE (DO NOT USE 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

38. PLACE OF FINAL DISPOSITION (FULL PHYSICAL ADDRESS REQUIRED) 39. TYPE OF DISPOSITION 40. EMBALMING

42. NAMEOF FUNERAL ESTABLISHMENT 43. LICENSE NUMBER

45. PLACE OF DEATH 46. IF HOSPITAL, SPECIFY ONE: 47. IF OTHER THAN A HOSPITAL, SPECIFY ONE

48. COUNTY 49. FACILITY ADDRESS OR LOCATION WHERE FOUND (Street and number or location) 50. CITY

Date of Arrangements ______________

IP

Residence YES

HospiceER/OP

Cemetery NO

NursingHome/TLC

DOA

Scatter at Sea

Decedent’sHome

Other

YES ______________________________________________________ NO

YES NO UNK

DEC

EDEN

T’S

PER

SON

AL

DAT

AU

SUA

L R

ESID

ENC

EIN

FOR

MA

NT

SPO

USE

AN

D P

AR

ENT

INFO

RM

ATIO

NPL

AC

E O

F D

EATH

DIS

POSI

TIO

N/

*SINGLE IS NOT ACCEPTED______

DUGGAN'S MISSION CHAPEL

PHONE NUMBER

FD-903

TYPE OF ARRANGEMENTS:

DEATH CERTIFICATE(S)

RELEASE TO:_________________________________________________

MAIL TO:_____________________________________________________

Burial Cremation

IF CREMATED, RELEASE TO:__________________________________________

___________________ ___________________________________ Signature date

The majority of the vital statistics information above is required by the State Registrar and will appear on the original certificate of death. If information above is provided incorrectly, an Affidavit to Amend a Record may be necessary, resulting in additional fees for amended certificates of death, and a delay in obtaining those copies.

I, the undersigned, attest that the information provided above is accurate to the best of my knowledge.

FD-903525 West Napa Street

Sonoma, CA 95476(707) 996-3655

(707) 996-5479 FAX

#_____

newuserSign Here

DUGGAN’S MISSION CHAPEL – FD-903 525 West Napa Street, Sonoma, CA 95476

(707) 996-3655 OFFICE(707) 996-5479 FAX

ACKNOWLEDGEMENT OF DISCLOSURES

For your information, and in order that you have a concise knowledge of basic logistics and timeframes for completion of the following processes, we clarify for you in writing regarding

Deceased: _____________________________________________

CREMATION PROCESS The cremation process cannot be performed until the attending physician or coroner has signed the death certificate. Once the death certificate has been signed, it will then be filed with the County of death. After it has been filed with the County of death, the County will then issue an Application and Permit for Disposition of Human Remains. After the permit has been issued, the cremation process will then be scheduled with our crematory. The timeframe for the legal paperwork processing and presentation of the cremation urn to you can take on average 7 to 10 business days.

RECEIPT OF CREMATED REMAINS We kindly ask that you retrieve your loved one’s cremated remains from the funeral home within 20 days from the date we notify you of completion.

CASKET BURIAL PROCESS The casket burial cannot be performed until the attending physician or coroner has signed the death certificate and the County has issued a burial permit. It is important to remember that it may take a few to several days to obtain a permit. Prior to scheduling/finalizing any funeral and cemetery ceremonies, our funeral directors will advise you on an approx. realistic timeframe in order to secure a burial permit.

ORDERING CERTIFIED COPIES OF DEATH CERTIFICATES Once the death certificate has been filed with the County of death and permit has been issued by the county, this is when your order for certified copies of death certificates will be submitted. The order can take approx. 2 weeks to process, depending on the County. Rest assured that we will work diligently in order that the documents are processed in a timely manner. All times stated above are estimates and cannot be guaranteed, and can be shorter or longer.

CORONER AMENDMENTS TO DEATH CERTIFICATES The Coroner may elect to present a “PENDING” death certificate. This means that they need additional time to investigate further in order to provide full/conclusive cause(s) of death. Coroner amendments may sometimes take many months to process and are not generated by the funeral home. You would have to specifically request a purchase of amended certificates at the time such amendment is registered with the State. Such corrections will never be reflected on the original death certificate, but would rather be a subsequent-page attachment (www.cdph.ca.gov).

PHYSICIAN’S SIGNATURE ON THE DEATH CERTIFICATE Occasionally, a physician may inadvertently make an error in the actual electronic, fax or voice attestation (signature) procedure of the death certificate. The State reserves the right to reject a death certificate submitted to it in such case. In this event, the State may temporarily withhold the ability for the funeral home or family to order the certified death certificates until the physician signs a replacement certificate and it is accepted by the State.

GENERAL ERRORS AND CORRECTIONS TO DEATH CERTIFICATES It is very important that full and accurate information be provided to the funeral home to complete the death certificate. In the event that an error was made on the original death certificate, an Affidavit to Amend a Record would have to be filed with the CA Dept. of Public Health, Death Registration Office and will present a delay in obtaining amended copies. Such corrections will never be reflected on the original death certificate, but would rather be a subsequent-page attachment (www.cdph.ca.gov). Errors on the death certificate may affect obtaining possible benefits and completing business and/or financial matters after a death occurs. Because mortality statistics are no more accurate than the information submitted on death certificates, it is very important that all death certificates be completed and filed accurately.

I have reviewed and understand the Acknowledgment of Disclosures.

Signature:________________________________ Printed Name:__________________________________

Dated:____________________

newuserSign Here

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)

newuserSign Here

DUGGAN’S MISSION CHAPEL – FD-903 525 West Napa Street, Sonoma, CA 95476

(707) 996-3655 OFFICE(707) 996-5479 FAX

AUTHORITY FOR RELEASE OF REMAINS AND PERSONAL EFFECTS

To: ____________________________________________ Date: _____________

I certify that I am the surviving_______________ to ____________________________ ,

whose date of birth is_____________ , and I further certify that I have the right to control

the disposition of the human remains and personal effects of the above-named decedent.

Please release the human remains and/or any personal effects to:

______________________________________________________________________

Name: ______________________________

Signature: ___________________________

Address: ______________________________________________________________

Telephone: _____________________________

newuserSign Here

AUTHORIZATION TO ACCEPT OR DECLINE EMBALMING

TO: ________________________________________ (Funeral Establishment Name)

RE: ________________________________________ (Decedent)

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.

I, ____________________________, do __ do not __ (check one) request embalming. I understand that for storage or embalming purposes the decedent may be transported to the following location:

______________________________________________________________________ (Location Name and Address)

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

Signed: ____________________________, Relationship to Decedent: _____________

Executed this ____ day of _______________, _____, at ________________________. (Month) (Year) (City and State)

This 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 ______________________________, Relationship to Decedent: _______________, who did __ did not __ (check one) authorize embalming at the above named funeral establishment. Telephone Number: _________________________ 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 ________________________.

(Month) (Year) (City and State)

________________________________ ________________________________ Funeral Establishment Representative (Print Name) Funeral Establishment Representative (Signature)

12-AUTH (rev. 11/14)

newuserSign Here

DUGGAN’S MISSION CHAPEL – FD-903 525 West Napa Street, Sonoma, CA 95476

(707) 996-3655 OFFICE(707) 996-5479 FAX

AUTHORIZATION FOR RELEASE OF DEATH CERTIFICATE(S)

I/We, the undersigned, hereby certify that I/We have the legal right to control disposition of the remains of ________________________________________, deceased, and subject to the following specific direction, I/We, the undersigned, unconditionally agree that death certificate(s) shall be released / mailed ONLY to:

__________________________________________, Relationship: ________________

# to pick up __________

# to mail __________......................FUNERAL HOME IS NOT RESPONSIBLE FOR LOSS OF ANY ARTICLES THROUGH MAIL.

If mailed, the address is: __________________________________________________________

I/We hereby certify that I/We have the right to make authorization and agree to release, indemnify and hold harmless the Funeral Home and its affiliates, officers, directors, shareholders, employees, representatives, agents, owners, successors, subsidiaries, parents and assigns from any and all liabilities, claims or cause of action arising out of, or in any way connected with, the release or mailing of the Decedent's death certificate(s) and My/Our representation, authorization and instructions contained herein.

Signed: _____________________________________________

Print: _______________________________________________

Relationship: _________________________________________

Date: _______________________________________________

Signed: _____________________________________________

Print: _______________________________________________

Relationship: _________________________________________

Date: _______________________________________________

Signed: _____________________________________________

Print: _______________________________________________

Relationship: _________________________________________

Date: _______________________________________________

newuserSign Here

newuserSign Here

newuserSign Here

AUTHORITY TO CREMATE

1. Cremation Container. The Crematory will not accept the remains of the Decedent for cremation unless they are in a leak-resistant, rigidcombustible cremation container or casket. I authorize the Crematory to remove and dispose of handles, ornaments or other non-combustible parts ofthe cremation container or casket.2. Mechanical or Radioactive Devices. Mechanical or radioactive devices, such as pacemakers, may be a hazard if placed in the cremationchamber. The Crematory will therefore not knowingly cremate any remains which contain such a device.I certify that the remains of the Decedent DO ________ DO NOT ________ contain a mechanical or radioactive device. (Place initials next tocorrect statement).If the decedent’s remains do contain such a device, I authorize the Funeral Establishment or Crematory to arrange for the removal of the device prior tothe cremation. I further authorize the Funeral Establishment or Crematory or its agent to dispose of any such device as it deems appropriate. I agree toindemnify and hold the Crematory harmless from any and all claims or damages, including damage to the retort(s) or injuries suffered by theCrematory’s employees, which arise from my failure to timely notify the Crematory of any mechanical or radioactive implants in the body of theDecedent. INITIAL: ________3. Mementos, Jewelry, Dental Gold/Silver & Other Foreign Materials. Items such as personal mementos, jewelry, dental gold and silver,prostheses and other foreign materials placed in the cremation chamber with the Decedent will either be destroyed or rendered unrecognizable. If anysuch items are recovered from the cremation chamber I authorize the Crematory to dispose of them.I4. The Cremation Process. I acknowledge the following: The human body burns with the casket, container, or other material in the cremationchamber. Some bone fragments are not combustible at the incineration temperature and, as a result, remain in the cremation chamber. During thecremation, the contents of the chamber may be moved to facilitate incineration. The chamber is composed of ceramic or other material whichdisintegrates slightly during each cremation and the product of that disintegration is commingled with the cremated remains. Nearly all of the contentsof 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 interment or scattering. Some residue remains in the cracks and uneven places ofthe chamber. Periodically, the accumulation of this residue is removed and interred in a dedicated cemetery property, or scattered at sea.5. Time of Cremation. The cremation will take place after all required permits are obtained, this completed and signed Authority to Cremate is received by the Crematory, and after any scheduled funeral ceremony at which the decedent’s body is to be present has been concluded. The Crematory will perform the cremation according to its schedule (unless a specific date and time is requested in section 9), and at it’s discretion, without obtaining any further authorizations or instructions, unless the right of the person signing this document to authorize the cremation is contested by someone. In that event the Crematory may delay the cremation while it determines whether and how to proceed. The normal cremation process may take a minimum of 3 working days to a possible 10 working days once all papers are signed and received at the Crematory.6. Viewing of Remains. In order to view the remains of the deceased, minimal preparation and charges apply in order to do so.I WOULD like to make arrangements to view the deceased’s remains _____________ initials OR (ONLY CHOOSE ONE)I DECLINE to make arrangements to view the deceased’s remains _____________ initials7. Weight Limits. In the event the Decedent is over 250 lbs., additional charges will apply.I certify that the Decedent is under 250 lbs. YES ________ NO ________ (Note: An additional charge will apply) (Place initials next to correct statement)

Page 1 of 2 (front)

Crematory ID Tag # ___________

NAME OF DECEDENT: _______________________________________________________________________SEX:

DECEDENT’S LAST RESIDENCE:_____________________________________________________________________________

(In this document the word “I” shall refer to all persons authorizing the cremation and disposition of the decedent.) I authorize Duggan’s Mission Chapel Crematory (the “Crematory”) to cremate the body of the decedent named above (the “Decedent”) in accordance with the Crematory’s rules and regulations and State laws and regulations. Funeral Establishment reserves the right to choose which Crematory will be used. [NOTE: California law provides “Any person signing any authorization for the interment or cremation of any remains warrants the truthfulness of any fact set forth in the authorization, the identity of the person whose remains are sought to be interred or cremated, and his or her authority to order interment or cremation. He or she is personally liable for all damage occasioned by or resulting from the breach of such warranty.”] I (We) certify that the decedent did not give directions that his/her remains not be cremated, and that (INITIAL ONLY ON APPLICABLE LINES):

________ I am making this authorization for myself.

________ I am the Agent under an Advance Health Care Directive (attach a copy of the Advance Health Care Directive).

________ I am the surviving spouse or the surviving California Registered Domestic Partner.

________ I am (We are) the surviving child (children- all or majority). _______ number of children.

________ I am (We are) the surviving parent(s). _______ number of parents.

________ I am (We are) all or a majority of the surviving sister(s) and brother(s). _______ number of sisters and brothers.

________ I am (We are) all or a majority of the surviving niece(s) and nephew(s). _______ number of nieces and nephews.

________ I am (We are) all or a majority of the surviving next of kin of closest degree of decedent as defined in California Probate Code 6400 et seq. and California Health and Safety Code 7100. Relationship:______________________________

________ I certify that I have the legal right to authorize the cremation & control the disposition of the Decedent’s remains. INITIAL

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserInitial Here

newuserInitial Here

newuserInitial Here

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

AUTHORITY TO CREMATE page 2 of 2 (Back) Crematory ID Tag # ___________ NAME OF DECEDENT: _______________________________________________________________________

DECEDENT’S LAST RESIDENCE:_____________________________________________________________________________

8. Disposition. I authorize the Crematory to release the cremated remains back to the Funeral Establishment. We offer a minimum plastic urn tohold the cremated remains.[NOTE: I understand that if the remains are not picked up within twenty (20) days after the cremation, the Funeral Establishment may deliver the

remains to a licensed cemetery for final disposition in a manner which may make the remains non-recoverable.]Mail the remains to __________________________________________________________________________________________________

(Name & Address) INITIAL: ________ Remains will be mailed via U.S. Postal Service, Priority Express Mail with return receipt requested. I understand that the Funeral Establishment is acting solely as my agent in mailing the remains, and I agree that the Funeral Establishment shall not be liable if the remains are lost or damaged once in the custody of the U.S. Postal Service. (Initials required only if this options was selected.)

INITIAL: ________Scatter at sea in Pacific Ocean, non-witnessed, non-recoverable off coast of _____________________________County, CA (Initials required only if this options was selected.)

[NOTE: I understand that the Funeral Establishment is acting solely as my agent as an accommodation to me in arranging for the scattering of the remains. I agree that the Funeral Establishment shall not be liable for any failure by the service named above to properly scatter the remains.]

9. Special Instructions. Indicate special instructions below, including request to witness the cremation:INITIAL:_________SPECIFY:________________________________________________________________________________________ _________________________________________________________________________________________________________________ URN(S):__________________________________________________________________________________________________________ INITIAL 10. Obligation of Crematory; Limitation on Damages. The obligation of the Crematory shall be limited to the cremation of the Decedent and thedisposition of the cremated remains as directed herein. I agree to release and hold the Crematory, its affiliated companies and their employees andagents harmless from any and all loss, damages, liability or causes of action (including attorneys’ fees and costs of litigation) in connection with thecremation and disposition of the cremated remains as authorized herein, or the failure to properly identify the Decedent or to take possession of or makearrangements for the permanent disposition of the cremated remains. No warranties, express or implied, are made by the Crematory and damages shallbe limited to the refund of the fee paid for the cremation.

SIGNATURES: The following persons authorize the cremation and disposition of the Decedent named above, and agree that a facsimile copy of this Authorization, or a copy of this Authorization with our electronic signatures, shall be as valid as an original.

WITNESS: IF THIS DOCUMENT IS NOT SIGNED BEFORE A STAFF MEMBER OF THE FUNERAL ESTABLISHMENT, PLEASE ATTACH A PHOTOCOPY OF PHOTO IDENTIFICATION WITH SIGNATURE, OR IF NO PHOTO ID, THEN ALL SIGNATURES NEED TO BE NOTARIZED.

__________ __________________________________________ __________________________________________ ___________________ Date Signature Print Name Relationship to Decd.

Address: ________________________________________________________________________________ Phone _______________________

__________ __________________________________________ __________________________________________ ___________________ Date Signature Print Name Relationship to Decd.

Address: ________________________________________________________________________________ Phone _______________________

__________ __________________________________________ __________________________________________ ___________________ Date Signature Print Name Relationship to Decd.

Address: ________________________________________________________________________________ Phone _______________________

__________ __________________________________________ __________________________________________ ___________________ Date Signature Print Name Relationship to Decd.

Address: ________________________________________________________________________________ Phone _______________________ SIGN SISIGN Name of Funeral Establishment: _________________________________________________________________________________________

Arrangement Counselor Printed Name and Signature: ______________________________________________________________________

Crematory: Duggan’s Mission Chapel Crematory, 525 W Napa Street, Sonoma, CA 95476, Phone # (707) 996-3655, License # CR-385

For more information on funeral, cemetery, and cremation matters contact: State of California Department of Consumer Affairs / Cemetery and Funeral Bureau, 1625 North Market Boulevard, Suite S-208, Sacramento, California 92834, (916) 574-7870.

newuserSign Here

newuserHighlight

newuserInitial Here

newuserSign Here

newuserSign Here

newuserSign Here

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.govnewuserSign Here

newuserSign Here

To start your webpage, an email will be sent to you requesting the following:• A photo of your loved one• Obituary information

Name:_____________________Email:_________________________________

Deceased Name:_________________________________

Signature:________________________ Phone Number:__________________

Date of birth:_____________" Date of death:_____________ Yes, sign me up to receive daily email affirmations which I can stop anytime

Obituary Memorial WebpageDuggan's Mission Chapel honors each and every family that comes through our doors. We would like

to continue honoring your family for years to come. One way is that we will create a memorial webpage for your family and friends to visit and engage in. You will all be able to post memories, photos, videos, light virtual candles, send flowers and sympathy gifts, as well as find out how to pledge memorial donations to the charity of your choice. Your family can also sign up for 365 days of grief support. Receive a daily affirmation by email and you can discontinue the emails anytime. There is no additional cost for webpage obituary services.

To engage the support of your Sonoma Community, we will automatically place your loved one's name and date of birth and death on our obituary webpage.*

If you decline to list your loved one on our community site, do not sign this form.

Funeral director to complete ceremony information:Date:__________ Service Location:_____________________ Times:____________

Go to: www.duggansmissionchapel.com/obituaries

Please list three key pastimes or accomplishmentsof your loved one:1_____________________ 2_____________________ 3_____________________Favorite type or era of music:______________________*Although this memorial webpage is designed to honor and engage communitysupport, we cannot be liable for postings of condolences, photos or videos.

Memorial Contributions:__________________________________

OPTIONAL FORM

newuserSign Here

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

newuserHighlight

ARRANGEMENTS FINALIZED REVVITAL STATISTICS INFORMATION CORRECTION FINALIZED

DISCLOSURESARRANGEMENTS FINALIZED REVPRENEEDRELEASEEMBALMINGAUTHORIZATION FOR RELEASE OF DEATH CERTIFICATEDuggan's Cremation Authorization ORIGINALDECLARATION

Memorial Webpage.pdf1.VITALS-12. Release2.b ReleaseCustody3. a Autho pg13. b Autho pg24.dec page5.emb form6.discl_preneed7. Release DC8. Ack Disclosure9. ReferralUntitled

Memorial Webpage.pdf1.VITALS-12. Release2.b ReleaseCustody3. a Autho pg13. b Autho pg24.dec page5.emb form6.discl_preneed7. Release DC8. Ack Disclosure9. ReferralUntitled

Memorial Webpage REVISION.pdf1.VITALS-12. Release2.b ReleaseCustody3. a Autho pg13. b Autho pg24.dec page5.emb form6.discl_preneed7. Release DC8. Ack Disclosure9. ReferralUntitled

Check Box83: OffText70: Text111: Text112: Text114: Check Box7: OffCheck Box8: OffDate and time authorization granted: Text118: AKA ALSO KNOWN AS Include full AKA: 7BIRTH STATEFOREIGN COUNTRY: 8 SOCIAL SECURITY NO: Check Box9: OffText2: Check Box10: OffCheck Box12: Off10 MARITAL STATUS: 11 EDUCATION Highest LevelDegree: Check Box25: OffYES_2: Check Box11: Off14 DECEDENTS 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 eg grocery store road construction employment agency etc: 17 YEARS IN OCCUPATION: 20 COUNTYPROVINCE: 22 YEARS IN COUNTY: 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: Check Box13: OffCheck Box14: OffCheck Box15: Off45 PLACE OF DEATH: Check Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box24: Off48 COUNTY: 49 FACILITY ADDRESS OR LOCATION WHERE FOUND Street and number or location: Check Box3: OffCheck Box4: OffCity of Birth: that death certificates shall be released mailed ONLY to: If mailed the address is: 25 INFORMANTS MAILING ADDRESS Street and number or rural route city or town state ZIP: 4 DATE OF BIRTH mmddccyy: 50 CITY: Text7: 38 PLACE OF FINAL DISPOSITION: number of children: number of parents: number of sisters and brothers: number of nieces and nephews: Crematory ID Tag: Name Address: County CA: SPECIFY: INITIAL 2: Text30: Print Name_2: Address 1_2: Phone_2: Print Name_3: Address 1_3: Phone_3: Print Name_4: Address: Phone_4: Dropdown31: [Duggan's Mission Chapel (FD-903)]18 DECEDENTS RESIDENCE Street and number or location: 6 SEX: 19 CITY: 21 ZIP CODE: 23 STATEFOREIGN COUNTRY: Image9_af_image: Informant name: Email: Text1: 5 DATE OF DEATH mmddccyy: Date: Text15: Times: Text3: Text5: Text8: Text9: Text10: Text11: Text16: