Vital Statistics Information

All information collected is confidential, Pine Box Funerals does NOT participate in sharing or selling any personal information collected. All fields are required. We understand that you may not have all of the information gathered at this time. Please write “unknown” for fields in which are unknown.

Deceased's Personal Information

Today's Date

YYYY

Deceased's Date of Birth:

YYYY

Date of Death

YYYY

Deceased's Full Legal Name (at time of birth)

First Name

Middle Name

Last Name

Deceased's Full Legal Name (at time of death)

First Name

Middle Name

Last Name

Sex of Deceased

Female

Male

Age

Deceased's Address (street, city, province)

Legal Marital Status

Common Law

Married

Divorced

Widowed

Never been Married

Deceased's Place of Birth (city, town or province, if known)

Deceased's Place of Death (address)

Deceased's Alberta Drivers License Number

Deceased's Social Insurance Number

Deceased's Alberta Health Care Number

Deceased's Type of Business (retail, accounting, construction)

Deceased's Occupation or "Position" (clerk, accountant, foreman)

Deceased's Parental Information

Parent 1 - First Name

Parent 1 - Middle Name

Parent 1 - Last Name

Parent 1 - Place of Birth (City, Province, Country)

If unknown, please enter "unknown".

Parent 2 - First Name

Parent 2 - Middle Name

Parent 2 - Last Name

Parent 2 - Place of Birth (City, Province, Country)

If unknown, please enter "unknown".

Informant Information

The person supplying the information above.

Informant's Full Name

First Name

Last Name

Informant's Daytime Phone Number

(###)

###

####

Relationship to the Deceased

Informant's Usual Residence

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Next of Kin or Executor Information

If the informant and next of kin/executor are the same person, you only need to fill out the information once.

Is there a Will?

Yes

Vital Statistics Information

Contact

Subscribe to the Pine Box Funerals Newsletter