If you do not have ability to scan the form with the data and signatures included, please fax to

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1 To: Gold Coast Cremation From: Phone: : Fax: Date: Total Pages Being Submitted: This paperwork is regarding (Check one): Advance Planning Imminent Death Death Has Occurred My Loved One is at (Check one): Coroner s Office Hospital Funeral Home Residence /Nursing Home Choice of Disposition: (Check one): Cremation Burial Instructions: Fill in and check the forms thoroughly, save forms as.pdf with data and to forms@goldcoastcr.com Fax Instructions: If you do not have ability to scan the form with the data and signatures included, please fax to Fax Cover Page 2. Vital Info Sheet 3. Main Contact & Next of Kin Info 4. General Release - Authorization (If Death Has Occurred) Response Time: Gold Coast Cremation answers the phone 24/7, we will respond and reply to your submitted paperwork during normal business hours M-F 8:30-4:30. If you need immediate help please contact us directly at

2 Gold Coast Cremation is your Dignified Low Cost Cremation & Burial Provider. We offer Low Cost Cremation & Burial options to families who want a basic cremation or simple burial service without a the hassle of a full service funeral home. In order to server our families in the most efficient and cost effective way possible, we have established a few terms of service. Terms of Service 1. If necessary a Signed Release must be submitted prior to taking your loved one into our care. 2. Decedents who pass away at home or at a nursing facility will be brought into our care immediately. We will pick up the decedent from a hospital or medical examiner/coroner s office during normal business hours after the cremation forms have been completed and a signed contract is completed. 3. Payment in full is required by Gold Coast Cremation prior to performing the act of cremation or transporting your loved one to a cemetery. 4. The decedent does not exceed the weight of 600 lbs. (Notice: There may be an additional fee for decedents over 250 lbs. Please call for additional information.) 5. Gold Coast Cremation will initiate transportation of the deceased into their care upon clearance from the nurse, officer or family member. I understand that if Gold Coast Cremation goes to pick up and is unable to do so due to the deceased not being ready, I can be charged the full line item cost of that service including any mileage and second attendant fees for that dry run. 6. The Legal Next of Kin signs authorization documents online using a secure, e-signing process, or downloads all forms necessary signs them then faxes or s to Gold Coast Cremation. See below for an explanation of who the Legal Next of Kin is in California. The California Health and Safety Code lists the person who have the legal right to make decisions about disposition arrangements after an individual s death unless other written instructions are left. They are listed below in the following order: Decedent Agent under DD Form 93 Agent under a Power of Attorney for Health Care Spouse or Registered Domestic Partner Child / Children over age of 18 (Majority) Parent / Parents Sibling / Siblings (Majority) Grandparents / Grandchildren (Majority) Great-Grandchildren, Nephews, Nieces, Uncles, Aunts, Great-Grandparents All persons must be competent, and, except for spouses and parent, all persons but be of at least 18 years of age. Domestic Partners must be registered with the Secretary of California. Decedent s wishes my comply with the Health & Safety Code Section to be binding.

3 Name of Decedent (First, Middle, Last): Vital Info Sheet Date of Birth: Age: Sex: Birth State: Social Security Number: Marital Status (Do Not List as Single) : Highest Education: Served in US Armed Forces: Date of Death: Was Decedent Hispanic, Latino or Spanish: Decedent s Race (If Hispanic, What Country of Origin): Usual Occupation (Do Not Use Retired): Kind of Business or Industry: Yrs in Occupation: Decedent s Address: County of Residence: Yrs in County: Informant s Name / Relationship: Informant s Mailing Address: Surviving Spouse (First, Middle, Last, Maiden): Full Name of Father: Full Name of Mother (Maiden): State of Birth (Father): State of Birth (Mother): Place of Final Disposition: (Name of Cemetery, Residence, Scattering at Sea, Scattering Over Land) The information below will be used on the official Death Certificate. It is imperative that it be accurate. If any box is left blank, we will assume it is unknown and follow the guidelines of the State s Electronic Death Registry System. I state that the information above is true and correct. Further, I release Gold Coast Cremation from any charges that may occur in the correction of the original due to this information. Signature: Date:

4 Main Contact & Next of Kin (As Listed on Pg. 2) Main Contact: (Person Coordinating Final Arrangements May Also Be Next of Kin) Next of Kin #1 Next of Kin #2 Next of Kin #3 Next of Kin #4

5 Authorization For Release Name of Decedent: Date of Birth: (MM/DD/YYYY) I hereby certify as signed below, that in accordance with the wishes and majority approval of all others so authorized by SS.7100 of the California Health and Safety Code, I have the right to control the disposition of the above named decedent.i understand that if I choose to use another funeral home after Gold Coast Cremation has picked up my loved one I will be responsible for the removal charges ($295) as well as any and all storage, additional mileage, and second attendant removal charges. I direct that the remains of the above named decedent be released or delivered without delay to Gold Coast Cremation or its agent upon request. To the best of my knowledge the deceased Does, or Does Not, have any communicable diseases or been exposed to one, and Does, or Does Not, have a pacemaker or any other implanted radioactive device. All valuables and/or personal property of the decedent are to remain at the place of death until further notice unless I specifically authorize in writing Authorized Signature Date Signed Authorizer s Printed Full Name Authorizer s Primary Phone Authorizer s Full Street Address, City, State and Zip Code Driver s License # or ID # I hereby agree to hold Gold Coast Cremation harmless and to indemnify it or its assignees and/or its agents from any and all claims, demands or damages which may be made or declared by reason of their acting according to this authorization. Location of Deceased: Facility Name Facility Full Street Address, City, State and Zip Code