First Name:
Middle Name(s):
Last Name:
Name Known By:
SIN:
Date of Birth:
Birth Place: (Town, Province, Country)
Usual Residence Address:
City:
Province:
Postal Code:
Phone:
Email:
Father's Name:
Birth Place: (Town, Province, Country)
Mother's Maiden Name:
Birth Place: (Town, Province, Country)
Maiden Name of Spouse:
Marital Status:
Date of Marriage:
Place:
If deceased, date of death:
Children: (List Child's Name, Spouse's Name, City and Province.)
Current Number of Grandchildren:
Current Number of Great Grandchildren:
Names of Surviving Brothers And Sisters And Their Address: (List Name, City, Province)
Preceded in death by:
Occupation: (Give the type of work done most of working life, even if retired.)
Name of Employer:
If Retired, Date of Retirement:
Total years spent in your occupation:
Church affiliation and activities:
List membership in fraternal, civic, or professional organizations:
Did you serve in the military :	Yes   No
List Military Service:

Funeral Instructions

Place of Service:
Minister:
Minister:
Music Selection:
Organist:
Singer(s):
Pallbearers:
Favorite Bible Selections:
Special Services (Military or Lodge):

Cemetery Information

Name of Cemetery:
Location City:
Lot Purchaser Name:
Section:
Lot:
Grave Space:

Casket And Burial Preferences

Casket Material:	Metal   Wood
Burial Vault:

Authorized Persons To Arrange Final Details

Person's Name:
Relationship:
Address:
City:
Province:
Postal Code:
Phone:
Email:
Alternate Person's Name:
Relationship:
Address:
City:
Province:
Postal Code:
Phone:
Email:
My Special Wishes: (Clothing, jewelry, etc.)
Would you like to be contacted to discuss the details of your funeral prearrangements?	Yes   No
Any Other Information We Might Need Before Contacting you (eg. Is there a preferred time of day for a telephone call?)
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