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Your information (Person Reporting Death)

First name

Middle Name

Last name

Email address

Phone number

Alternate phone number

Address

Relationship to your loved one *

Are you the executor, next of kin or authorized decision maker?

Yes No

Your Loved One's Information

First name

Middle name

Last name

Preferred name

When was your loved one born?

When did your loved one pass?

Age of your loved one

Sex of your loved one

Male Female X

Where is the your loved one currently located?

Deceased's Primary Residence

SIN Number

Parents of the Deceased

Mother

First Name

Middle name

Last Name

Maiden Name

Suffix

Life status

Living Deceased

Place of Birth

Father

First Name

Middle name

Last Name

Suffix

Life status

Living Deceased

Place of Birth

Current Relationship Status

Marital Status at Time of Death

Spouse Gender

Male Female X

Spouse First Name

Spouse Middle Name

Spouse Last Name

Spouse Maiden Name

Spouse Known As

Spouse Phone Number

Spouse Social Insurance Number

Spouse is veteran

Yes No

Spouse Life Status

Living Deceased Unknown

Spouse DOB

Spouse DOD

Spouse Age at Deceased Death

Address same as Deceased?

Yes No

Address

Written Communications Prefered Language

English

French

Verbal Communications Prefered Language

English

French

Receiving or have ever applied for any benefit

Canada Pension Plan

Old Age Security

Quebec Pension Plan

Marriage Details

City

Country

Date of Marriage

Marriage in Years

Additional Information

Is there a pacemaker implant present?
For safety, we will remove the pacemaker prior to cremation

Yes

No

Is there a radioactive implant present?
Radioactive implants refers to the medical procedure brachytherapy, involving permanently implanting radioactive seeds in a localized area. This does not change your ability to be cremated, it is simply beneficial for our team to know prior to cremation.

Yes

No

I declare that I am legally authorized to make, or charged with the responsibility for, the arrangements contained in this form.

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Cremation

Your information (Person Reporting Death)

First name:

Middle Name:

Last name:

Email address:

Phone number:

Alternate phone number:

Address:

Relationship to your loved one:

Are you the executor, next of kin or authorized decision maker?:

Your Loved One's Information

First name:

Middle name:

Last name:

Preferred name:

When was your loved one born?:

When did your loved one pass?:

Age of your loved one:

Sex of your loved one:

Where is the your loved one currently located?:

Deceased's Primary Residence:

SIN Number:

First Name:

Middle name:

Last Name:

Maiden Name:

Suffix:

Life status:

Place of Birth:

First Name:

Middle name:

Last Name:

Suffix:

Life status:

Place of Birth:

Current Relationship Status

Marital Status at Time of Death:

Spouse Gender:

Spouse First Name:

Spouse Middle Name:

Spouse Last Name:

Spouse Maiden Name:

Spouse Known As:

Spouse Phone Number:

Spouse Social Insurance Number:

Spouse is veteran:

Spouse Life Status:

Spouse DOB:

Spouse DOD:

Spouse Age at Deceased Death:

Address same as Deceased?:

Address:

Written Communications Prefered Language:

Verbal Communications Prefered Language:

Receiving or have ever applied for any benefit:

Marriage Details

City:

Country:

:

Date of Marriage:

Marriage in Years:

Your loved ones additional information

Is there a pacemaker implant present?
For safety, we will remove the pacemaker prior to cremation">Is there a pacemaker implant present?
For safety, we will remove the pacemaker prior to cremation:

Is there a radioactive implant present?
Radioactive implants refers to the medical procedure brachytherapy, involving permanently implanting radioactive seeds in a localized area. This does not change your ability to be cremated, it is simply beneficial for our team to know prior to cremation.">Is there a radioactive implant present?
Radioactive implants refers to the medical procedure brachytherapy, involving permanently implanting radioactive seeds in a localized area. This does not change your ability to be cremated, it is simply beneficial for our team to know prior to cremation.:

:

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Please make sure all details are correct before submitting

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