Eco Funeral Arrangement Checklist
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1
2Funeral Arrangement Checklist
Please note: Items 1 - 22 are required for funeral arrangements. See next page for
additional items. Unknown information can be entered as unknown.
1. Last Name
2. Social Insurance Number (optional)
3. First and Middle Names
Sex (M/F)
4. Date of Death (d/m/y)
5. Date of Birth (d/m/y)
6. City and Province where born (If outside Canada, state country)
Age at Time of Death (years)
If less than a year (months and days)
If less than a day (hours and minutes)
7.
Place of death (facility or location)
hospital
nursing home
residence
other (please specify)
8.
City, town, village or township
Regional municipality, county or district
Name of physician, coroner,
10. Marital relationship status (check one)
9.
other who pronounced death
single
married
widowed
divorced
common-law
same-sex partner
Last name of the deceased spouse of partner (before this marriage or relationship)
11.
Type of work done most of working life
Type of business or industry that the deceased worked in
12.
13.
most of working life
Deceased’s usual residence (street number and name, city, province, postal code (do not use post office box or rural route)
14.
City and province where father was born (if outside Canada,
Father’s name (last, first)
15.
16.
state the country)
City and province where mother was born (if outside Canada,
Mother’s maiden name (last, first)
17.
18.
state the country)
TO BE COMPLETED ONLY BY THE PERSON PROVIDING THIS INFORMATION
Name (last, first, middle)
Relationship to deceased
21. Signature
19.
20.
x
Address (Street number and name, city, province, postal code)
Date (d/m/y)
22.
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Parent category: Life