I. Biographical Information
Full Name:
Address1:
Address2:
City Name:
Province:
- - Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Territories
Postal Code:
Telephone Number:
Email Address:
Date of Birth:
City of Birth:
Province of Birth:
- - Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Territories
Social Insurance Number:
For security reasons, we will contact you to complete the pre-arrangement.
Residence History:
Father's Name:
Father's City of Residence:
Mother's Name:
Mother's City of Residence:
Mother's Maiden Name:
Spouse's Name:
Spouse's Maiden Name:
Survivors' Names and Cities of Residence
Relatives Who Have Preceded You In Death
Your Occupation:
Business Type:
Company Name:
Church Membership:
Lodge or Union Name:
Veteran:
Yes No
Branch of Service:
None Canadian Armed Forces Canadian Navy Canadian Air Force Canadian Coast Guard
Serial Number:
Date Enlisted:
Date of Discharge:
Rank at Discharge:
Location of a Copy of Discharge:
Time of Military Service:
Not a Veteran Peacetime World War I World War II Korean War Vietnam War Persian Gulf War
Military Honors at Graveside:
Not a Veteran Yes No
Flag Preference for Service:
None Drape Casket with Flag Folded Flag on Casket
III. Service Preferences
Type of Service:
Please Select One Service at Funeral Home Church Graveside Life Appreciation Service None
Visitation Hours:
Please Select One Two Days Visitation One Day Visitation Visitation & Service Same Day None
Casket:
Open for service Closed for service No public viewing
Person in Charge of Arrangements:
Officiating Clergy:
Pallbearers:
Flower Preference:
Music Selection:
Jewelry:
No jewelry Give to family Leave jewelry on
Glasses:
No glasses Donate Leave on Give to family
Casket Preference:
Select a Casket Bronze Copper Stainless Steel Steel (sealing) Minimum Metal Mahogany Walnut Cherry Oak Maple Poplar Pine Fiberboard / Veneer
Disposition:
Select Disposition Ground burial Mausoleum Cremation
Outer Container Preference: (for ground burial)
Select a Burial Container Concrete Vault (air tight protective vault) Metal Lined Concrete Vault (air tight protective vault) Concrete Grave Liner (structural protection only)
Cemetery Name:
Cemetery Location:
The cemetery property is in the name of:
Miscellaneous Notes and Instructions:
