York and Miramichi Valley Funeral Homes

Full Name
Date of Birth
Place Of Birth
Street Address
City		Province
County		Postal Code
Phone		Email
Spouse's Name		Spouse's Family Name
Father's Name		Father's Birthplace
Mother's Name		Mother's Birthplace
Mother's Maiden Name
Affilliations & Organizations
Education And Work History
Education
Additional Information
Occupation
Where
Additional Information
Military Service
Service Branch		Regimental Number
Date Enlisted		Date Discharged
War or Conflict
Funeral Preferences
I prefer my funeral service to be		Place of Service
Conclude Service at		I Prefer
Service Conducted By		Name
Religious Denomination
Place of Worship
Type of Clothing
Preferred Casket Type
Please List Musical Selections to be played
Persons Requested to Read or Sing
Favorite Bible Passages
Favorite Literature or Poems
Favorite Flowers
Final Disposition
Preference for final disposition
Mausoleum Entombment
Ground Interment With
Cremation with
Name of Cemetery
Location of Cemetery
The is owned at the above location
Special Instructions

Survivors
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Name		Relationship
Person to Finalize Funeral Arrangements at Time of Death
Name
Relationship
Address
City/Prov/Postal Code
Phone		Email
Please Select One Of The Choices Below
Please Send Information of Preplanning
Please Contact Me Concerning an Appointment
Please hold my information on file for future reference