Requested Statistical Information Page

Once again, our sincere condolences on the loss of your loved one. Please know that we are here 24 hours a day to assist you in whichever way we can. If you need to speak with us for any reason, please don’t hesitate to call us at 365 833 0052.

When you have a moment, please complete as much of this information form as you can. Not all of the information is essential, however the more information you can provide, the better we will be able to assist you moving forward.

Rest assured this information is kept completely confidential and is only used for our service documents and the federal/municipal registrations.

Name of the Deceased

First Name

Last Name

Middle Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Sex

Male

Female

Place of Birth

Marital Status

Name of Spouse

Social Insurance Number

Occupation (prior to retirement)

Their father's name and place of birth (if known)

Their mother's name, maiden name and place of birth (if known)

Where is your loved one now?

Please provide the name of the facility or address

Do they have a pacemaker or radioactive implant?

Yes

Unsure

Name of Executor or Next of Kin

First Name

Last Name

Relationship

I am their -

Address of Executor of NOK

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####