vital info

The following information is required for Magner-Maloney to complete a valid California death certificate.

This information can be completed after a passing or for prearrangement purposes.

First Name (required):

Middle Name:

Last Name (required):

Nickname(s):

Phone Number (required):

Email Address:

Date of Birth:

Place of Birth:

Social Security Number:

Marital Status:

U.S. Veteran:

Education Level:

Race:

Usual Occupation:

Type of Industry:

Years in Industry:

Street Address:

City:

County:

State:

Zip Code:

Years in County:

Spouse's First Name:

Spouse's Middle Name:

Spouse's Maiden Name:

Father's First Name:

Father's Middle Name:

Father's Last Name:

Father's State of Birth:

Mother's First Name:

Mother's Middle Name:

Mother's Maiden Name:

Mother's State of Birth:

Arrangement Type:

Is this Information being provided for:

Name of Person Completing this Information (or same as above):

Address of Person Completing this Information (or same as above):

Phone Number and Email of Person Completing this Information (or same as above):