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Personal Information
First Name*:
Middle Name:
Last Name*:
 
 
Your Email*:
Day Time Phone*:
Evening Phone:
 
 
Address:
City:
Province:
Postal Code:
 
 
Date of Birth:
January
February
March
April
May
June
July
August
September
October
November
December
1
2
3
4
5
6
7
8
9
10
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15
16
17
18
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23
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25
26
27
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29
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31
,
e.g. January 1, 1930
City of Birth:
Prov. of Birth:
Country of Birth:
 
 
Marital Status:
Never Married
Married
Divorced
Widowed
Family Members:
(i.e. - John Doe (son), Jane Doe (daughter), John Doe Sr. (brother), etc.)
Sex:
Male
Female
S.I.N Number:
Ontario Health
Card Number:
Occupation:
Industry:
Veteran:
Yes
No
If yes, DVA
Regimental Number:
 
 
Spouse's Full Name:
Spouse's
Maiden Name:
Mother's Full Name:
Mother's
Maiden Name:
Mother's Birth Place:
Father's Full Name:
Father's Birth Place:
 
 
Funeral Service Information
Type of Service:
Traditional Earth Burial
Cremation Memorial Service
Cremation Immediate Care
Place of Service:
Barclay Funeral Home Chapel
Graveside
Church
Name of Church:
Religious Denomination:
Viewing For Family:
Yes
No
Viewing For Friends:
Yes
No
Name of Cemetary:
Cemetary City:
Plot Location
Numbers (if known):
Memorialization
for Cremation
(if applicable):
Columbarium
Burial Plot
Scattering
Reception Following
Services (if applicable):
Barclay Funeral Home
Church Facility
Other (indicate below)
 
Favourite Musical
Selections:
Favourite Bible
Passages, Literature,
Poems or Readings:
Special Instructions
and Requests :
My Executor, Family Member or Close Friend to Finalize Arrangements at Time of Death
Name:
Relationship:
Address:
City:
Prov/State:
Day Phone:
Evening Phone:
Options:
Call me to arrange an interview
Keep my information on file
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Jesse Johnstone
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