Olinger~Saenz Mortuary Service
Heritage Oaks Mortuary
THIS INFORMATION IS NEEDED FOR US TO FILE THE DEATH CERTIFICATE. UPON COMPLETING ALL THE
INFORMATION PLEASE CALL 210-337-9999, FAX 210-337-9997 OR E-MAIL: heritage@
OFFICE HOURS ARE MONDAY-FRIDAY 8:00 AM – 4:15 PM
Information for Death Certificate
Name_____________________________________ _____________________________________ _________
| (First) (Middle) | (Last) (Maiden) |
|Date of Death ______/______/______ |Sex Male or Female |
| |Age____________ Years/Months/Days/Hours/Minutes |
|Date of Birth _________/_______/_______ |Social Security # ________-_______-________ |
| | |
|Birthplace__________________________ (City & | |
|State or Foreign Country) | |
Marital Status (Please Circle) Married, Widowed, Divorced, Never Married, Unknown
Surviving Spouse____________________________________(If wife, Please give Full Maiden Name)
Residential Address_______________________________________ City___________________________
County__________________ State______ Zip Code___________ Inside City Limits Yes or No
Father’s Name __________________________________________________________________________
Mother’s Full Maiden Name_______________________________________________________________
Highest Education Level Completed ____________________________
(If College, Specify Degree or some College but no Degree)
Of Hispanic Origin Yes or No If Yes, Specify______________________________________
(Mexican, Puerto Rican, Cuban, etc…)
Race__________________
Ever in Armed Forces Yes or No Branch of Service ___________________________________
Usual Occupation of Deceased – (Before he/she Retired)___________________ ______________________
Occupational Business or Industry _________________________________________________________
Informant’s Name ___________________________________________ Relationship ________________
Informant’s Mailing Address ______________________________________________________________
Informant’s Telephone #__________________________________________________________________
Informant’s E-mail address________________________________________________________________
Name of Cemetery_______________________________________________________________________
Location of Cemetery (City and State)_______________________________________________________
Place of Death:____________________________________________Hospice:_______________________
Time of Death: _______:_______AM/PM Dr.’s Phone #: ______________________________
Dr. to sign D/C: ______________________________Address to Dr:______________________________
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