Pre-Arrangement and Funeral Arrangement Form

Vital Statistics Record

Last Name:	Social Insurance Number:
First and Middle Name:	Sex:	M F
Address:	Unit:
City:	Province:
Postal Code:
Tel (H):	Tel (W):
Tel (C):	Email:
Date of Birth:	City of Birth:
Province:	Country:
Occupation:	Marital or relationship status:
Name of Spouse/Partner:	Spouse's Maiden Name:
Name of Father:	Father's Place of Birth:
Name of Mother:	Mother's Place of Birth:

Next of Kin:	Relationship:
Address:	Unit:
City:	Province:
Postal Code:
Tel (H):	Tel (W):
Tel (C):	Email:

Type:
Cremation
Crematorium:
Disposition of Cremated Remains:
Interment / Entombment
Church:		Chapel:
Other Facility (address):
Visiting:	yes no	Religion:
Officiating Clergy:
Hymns Preferred:
Music Selection:
Pallbearers:	family funeral home
In Memoriam Donation:

Immediate Family Members - Spouse:
Sons / Daughters:
Grandchildren:
Brothers / Sisters:

	Enter the code you see above in the field below.