Barclay Funeral Home - Brockville Funeral Director, Funeral, Cremation, Memorial Services

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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:	, e.g. January 1, 1930
City of Birth:
Prov. of Birth:
Country of Birth:

Marital Status:
Family Members: (i.e. - John Doe (son), Jane Doe (daughter), John Doe Sr. (brother), etc.)
Sex:
S.I.N Number:
Ontario Health Card Number:
Occupation:
Industry:
Veteran:
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:
Place of Service:
Name of Church:
Religious Denomination:
Viewing For Family:
Viewing For Friends:
Name of Cemetary:
Cemetary City:
Plot Location Numbers (if known):
Memorialization for Cremation (if applicable):
Reception Following Services (if applicable):

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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