Name(Surname & All given names)-This field is required to submit this form:

Social Insurance #:
E-mail-This field is required to submit this form:


City/Town:   Province/State:  
Country:             Postal/Zip Code:

Telephone: Fax:

Place of Birth (City, Province, Country):

Birth Date:

Occupation (Type of employment during majority of career):

Employer/Type of Industry/Business:

Marital Status (Select one):
Married Single Divorced Widowed Separated Common-law

Full Name of Spouse (Surname/Maiden Surname - All Given Names):

Father's Full Name:
Birthplace:

Mother's Full Maiden Name:
Birthplace:

Choice for Final Disposition (select one): Burial Cremation

Do you own a Cemetery Plot (select one): Yes No

If Yes - Name and Address of Cemetery:

           - Plot Information:

If No - Name of Cemetery of Choice:

Casket/Container Chosen (model#, name, manufacturer):

Outer Case for Cemetery (select one): None Liner Vault

Cremation Urn Chosen (model#, name, manufacturer):

Cremation - (Name of Crematorium):

Disposition of Cremated Remains (Cemetary, Return to Family or Other-specify):

Embalming (select one): Yes No     Viewing (Select one): Private (Family only) Public (Open casket) Public (Closed casket)

Death Notices - (List newspapers to be published in):

Religious Affiliation:

Officiant for Service (Clergy, Chaplain, Padre, Friend,etc.):

Donations (specify charity(s) to which in Memoriam donations could be made):

Community Involvement - (List Club Memberships, Fraternal Organizations, etc.):

Bearers - (Casket, Honorary, Flower etc):

Survivors: - (Will be reviewed and updated at time of death):
Parent(s):

Spouse:

OTHERS (List in order of age with address and telephone):
Son(s): (include daughter(s)-in-law's first name, (if married):

Daughter(s): (include son(s)-in-law's first name, (if married):

Brother(s): (and name of spouse, if married):

Sister(s): (and name of spouse, if married):

Grandchild(ren): (number or list names if desired):

Great grandchild(ren): (number or list names if desired):

Lawyer: (name address and telephone/fax/email):

Do you have a Will? (select one): Yes No

Executor: (name address and telephone/fax/email):

Would you prefer to prepay the funeral arrangements in order to offset any increase in cost of the Funeral Services and Merchandise?
(select one): Yes No

Special Requests and/or Notes:

It is my understanding that while not legally binding to my heirs/executor, the above represents my personal wishes as to my funeral arrangements. I further understand that if I wish to alter said arrangements and/or make additions or subtractions, the funeral home will produce the documents upon my request.

Name:       Date: