CA-EDRS Communication Sheet - Los Angeles County ...
California Electronic Death Registration System (CA-EDRS)
Fax Sheet – Los Angeles/Pasadena/Long Beach
|Date: |County of Death (LRD): |
|LRD Fax Number: |LRD Telephone Number: |
|Name of Funeral Home: |
|Contact Name at Funeral Home: |
|Telephone Number: |Fax Number: |
| |
|Name of Decedent: | | | |
|(First) (Middle) (Last) |
|Date of Death: |EDRS Record #: |
Please check all boxes that apply:
□ Unlock record
□ PI (This will delete the embalmer’s signature.)
□ MI (This will delete the physician and/or coroner’s signature.)
□ CI (This will delete the coroner’s signature.)
MUST State reason: ___________________________________________________________
□ MI Review
□ Amendment submitted: □ General □ Coroner
For multiple dispositions: LRD Use only
□ DC for multiple dispositions submitted for registration DC Registered __________
□ Amendment Submitted Amend Applied _________
□ Abandon record: □ DC □ Amendment # ________________
MUST State reason: ___________________________________________________________
□ Do not issue permit # ___________________
□ Ship Out/International Disposition or Religious Burial (Expedited Service)
□ CA-EDRS File Drop to Paper
(Please fax 100% working copy of burial permit and signed drop to paper death certificate with this form.)
□ Request for Non-Contagious Disease
□ Other ___________________________________________________________________________
Local Registrar Use Only
Staff initials: ________________________________ Date: ____________________________________
Remarks: _______________________________________________________________________________
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