Simple Choice Pre-Arrangement Form

Your Information

Full Name*:

Email Address*:

Phone Number:

Address:

Date of Birth:

City of Birth:

Birth Province:

Spouse's Information

Spouse's Name:

Spouse's Maiden Name:

Spouse's Address:

Father & Mother Information

Father's Name:

Father's City of Residence:

Mother's Name:

Mother's Maiden Name:

Mother's City of Residence:

Work & Education

Education:

Your Occupation:

Kind of Business:

Company Name::

Military Information

Branch of Service:

Serial Number:

Date Enlisted:

Rank at Discharge:

Date Discharged:

Discharge on File at:

Copy of Discharge Papers:

Yes

Disposition Information

I Prefer:

Cemetery:

Address:

Phone:

I Have Made A Last Will & Testament:

Yes

Additional Information

Flower Preference:

Music Selections:

Casket Pallbearers:

Jewelery:

Glasses:

Clothing:

Special Instructions

Other Information:

Memorials & Charities:

Send Information

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WINDSOR/Essex county (519) 254-2585

LONDON/MIDDLESEX COUNTY (519) 659-2163

CHATHAM-KENT county (519) 354-2585

Simple Choice Pre-Arrangement Form

Your Information