byersfuneralhome@primus.ca
2990 Church St., South Mountain, ON
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Pre-Planning Form
Name
*
First
Middle
Current Surname
Address
*
Street Address
Address Line 2
City
Province
Postal Code
Phone
*
Marital Status:
*
Single
Common Law
Married
Widowed
Divorced
Name of Spouse or Partner
First
Middle
Last
Occupation (when working)
*
Mother's Name
*
First Name
Maiden Name
Mother's Birthplace
*
Father's Name
*
First
Last
Father's Birthplace
*
I wish my funeral to be:
*
Public
Private
I wish for my services to be held at:
*
My preference for burial arrangements and other instructions:
*
My church affiliation is:
I would prefer as clergyman:
Please list any other instructions or remarks:
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