HomeMy WebLinkAboutvital-registration-service-request-form
ALAMEDA COUNTY HEALTH CARE SERVICES AGENCY Colleen Chawla, Director
PUBLIC HEALTH DEPARTMENT Kimi Watkins-Tartt, Director
Nicholas Moss, MD, MPH, Health Officer
Vital Registration John Serrano, Deputy Registrar
1100 San Leandro Blvd. (510) 267-8074
San Leandro, CA 94577 FAX: (510) 273-3766
□ California Electronic Death Registration System (CA-EDRS) □ California Fetal Death Registration System (CA-FDRS) Service Request Fax Sheet
Date: _________________________________________ City of Death: _______________________________
LRD Fax: _____________________________________ LRD Telephone: ______________________________
Name of Decedent/Fetus: _________________________ _______________ ____________________________
First Middle Last
Date of Death/Event: _____________________________ EDRS/FDRS Record #: ________________________
Please check all boxes that apply:
□ Unlock record
EDRS FDRS
□ PI (Delete embalmer’s signature) □ PI (Unlocks Personal Information)
□ MI (Delete physician/coroner’s signature) □ MH (Unlocks Medical History)
□ CI (Delete coroner’s signature) □ PC (Delete physician/coroner’s signature)
□ FD (Delete embalmer’s signature)
State reason: _______________________________________________________________________________
□ MI Review (For Fetal Death) *Please allow up to 2 hrs. of submission.
□ LR Review (For Fetal Death) *Please allow up to 2 hrs. of submission.
□ Issue permit # _________________________
□ Religious Burial (Expedited Service)
□ Request for Non-Contagious Disease Letter *For transit out of the country. Number of DC Copies: ________
□ Other ____________________________________________________________________________________
___________________________________________________________________________________________
Name of Funeral Establishment: _____________________________________________________________________
Contact Name: ___________________________________________________________________________________
Telephone: ________________________________________ Fax: ___________________________________
Local Registrar Use Only
Staff initials: _______________________________________ Date: __________________________________ Remarks: _______________________________________________________________________________________