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Death Certificate Order Form

Possible reasons/needs for ordering a death certificate include:

  • Life Insurance Proceeds
  • Sell or transfer stocks and bonds
  • Sell or transfer Real Property
  • Veterans Benefits
  • Social Security Benefits
  • Employee benefits and pensions
  • Bank and Loan transactions
  • IRS for Income Tax records

Thanks for taking the time to fill out our Death Certificate Request Form. The information provided on this form will help Cusimano Family Colonial Mortuary complete the death certificate.

Please complete (as much as possible) the information on the form and select 'Submit Request' at the end to send the request to us.

If you have any questions whatsoever, please contact Cusimano Family Colonial Mortuary at: 650-968-4453

NOTE: Fields marked with an asterisk ( * ) are required. Any information you submit will be held in the strictest confidence - we do not release any information to outside parties under any circumstances.

Deceased Vital Statistics for Death Certificate:

* Deceased First Name:
* Deceased Last Name:
Street Address:
Zip Code:
Date of Birth:
Place of Birth: City:


Date of Death:
Place of Death - Location:

If other location, please indicate:

Place of Death - Name:
Place of Death - Street:
Place of Death - City:
Place of Death - State
Place of Death - County:
Full Name of Surviving Spouse:
Death Certificate Quantity Requested:
First copy: $ 12.00
Each additional copy: $ 12.00

Informant/Person In Charge Information:

* First Name:
* Last Name:
Relationship To Deceased:
* Email Address:
Telephone Number:

Other Information & Instructions

Please list any other information or instructions you would like us to have:

Cusimano Family Colonial Mortuary   •   96 West El Camino Real, Mountain View, CA. 94040   •   650-968-4453   •   FD1041      •   Maps & Directions   •   Contact Us
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