 "Dignity with Economy" |
250 S. State Street, San Jacinto, CA 92583 951-654-2255 Toll Free 877-900-0095 Fax 951-654-2258 FD-1765 |
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WE CANNOT LEGALLY PROCESS ANY OF THESE FORMS IF THERE ARE ANY BLANK SPACES. If a question does not apply to your situation, enter N/A or, in the case of a dollar amount, a zero (0).
Read These Instructions Carefully to Ensure Timely Fulfillment of Your Needs and Desires
The information on this form is used by us to complete the information necessary for the non-medical portion of the official death certificate. YOUR SIGNATURE IS REQUIRED IN ONE PLACE ON THIS FORM. AUTHORIZATION FOR CREMATION AND DISPOSITION (2 pages) This form authorizes San Jacinto Valley Mortuary to handle the cremation of the deceased. YOUR INITIALS ARE REQUIRED SPECIFICALLY IN TWO PLACES ON PAGE ONE OF THIS FORM. YOUR INITIALS ARE REQUIRED IN UP TO 12 OTHER PLACES ON PAGE ONE OF THIS FORM. YOUR SIGNATURE IS REQUIRED IN ONE PLACE ON PAGE TWO OF THIS FORM. We will use your ID to witness your signature. ORDER FOR RELEASE (1 page) This form is a declaration that you have the right to control disposition according to state law and is also a written release if required by the facility of death. YOUR SIGNATURE IS REQUIRED IN ONE PLACE ON THIS FORM IF YOU ARE A NON-RELATIVE, YOUR SIGNATURE MUST BE WITNESSED. DISCLOSURE OF PRENEED FUNERAL ARRANGEMENT (1 page) This form makes explicit the existence or absence of a preneed arrangement. YOUR SIGNATURE IS REQUIRED IN ONE PLACE ON THIS FORM. AUTHORIZATION FOR DISPOSITION WITH OR WITHOUT EMBALMING (1 page) This form serves as written confirmation concerning your or your custodian’s desires about embalming. YOUR SIGNATURE IS REQUIRED IN ONE PLACE ON THIS FORM. FTC DISCLOSURE/DISCLAIMER (1 page) This form certifies compliance with FTC disclosure regulations. YOUR SIGNATURE IS REQUIRED IN ONE PLACE ON THIS FORM. DECLARATION FOR DISPOSITION OF CREMATED REMAINS (1 page) This form details the final disposition of the cremated remains. YOUR SIGNATURE IS REQUIRED IN TWO PLACES ON THIS FORM. SAN JACINTO VALLEY MORTUARY STATEMENT OF FUNERAL GOODS & SERVICES (6 pages) This is the order form, which details the goods and services you are ordering and their cost. CREDIT CARD CHARGE FORM (1 page) This form gives us permission to charge for the chosen goods and services to a credit card. SIGNATURE OF CARDHOLDER IS REQUIRED IN ONE PLACE ON THIS FORM. PURCHASE AGREEMENT This is the purchase contract, which details the agreement between you and San Jacinto Valley Mortuary. YOUR SIGNATURE IS REQUIRED IN ONE PLACE ON THIS FORM. 1. Print them out and fill them in by hand. 2. Using your computer, fill in the blue fields and places where checkmarks or choices are called for. Then print out the forms. Sign and initial the various forms where indicated. (California does not allow for “electronic signatures” at this time.) 1. A copy of a photo ID of EACH PERSON who signs these forms. THIS INCLUDES WITNESSES, as well as the person filling out the forms. The clarity of the photo ID is of utmost importance. The picture we receive through our fax machine must be clear enough that the person in the picture is recognizable. To be sure of this, have the photo ID enlarged to at least 250% of its original size and have the tone lightened to a certain degree. If you go to a duplication-and-fax service, the personnel there should know how to do this. If the photo that comes through is not recognizable, we will have to ask you to do it all over again. 2. COPY OF DURABLE POWER OF ATTORNEY FOR HEALTH CARE (IF APPLICABLE) 3. COPY OF CALIFORNIA REGISTERED DOMESTIC PARTNERSHIP CERTIFICATE (IF APPLICABLE) IMPORTANT NOTE ABOUT WITNESSES: The person filling out these forms cannot be his or her own witness. Order for Release Disclosure of Preneed Funeral Arrangment Authorization for Disposition With or Without Embalming Authorization for Cremation and Disposition Declaration for Disposition of Cremated Remains FTC Disclosure/Disclaimer Form Summary Totals of Goods and Services Ordered (page 6 of order form) Credit Card information Purchase Agreement Remember to also fax photo IDs of all signatories and witnesses and, if applicable, durable power of attorney and California registered domestic partnership certificate. BE SURE TO READ THE INSTRUCTIONS FIRST! (This is a 16-page PDF file that will open in a new window. It is somewhat large and will take some time to download. Please be patient.) |