H.W. Wallace Cremation and Burial Centre

Arrangement Form and Vital Statistics

Please fill out this convenient arrangement form. There is a place for further instructions and comments. Some one will contact you shortly to go over this with you.

This page is secure. All information you send will be kept in the strictest confidence.


Fields with a * are required.

Arrangement Form
Full Legal Name: *
Email:*
Tel:
I request Conventional Burial Cremation Green Burial
Type of Service Funeral Service Memorial Service
Graveside Service Alternate Service
No Service
I request that my service be held in:
Additional Instructions such as clergy, music, eulogy, flowers, charitable donations, memorialization, obituary, reception


The next two questions are for those who request burial
If Burial, City or Place of Cemetery
If Burial, Name of Cemetery

The next two questions are for those who request cremation
 
If cremation, I wish my ashes to be Returned to my Executor
Scattered
Buried
If Scattered or Buried, please describe where.


Vital Statistics
Full Legal Name: Example: Jones, John William
Sex Female Male
Complete Street Address: If rural give exact location (Not Post Office or Rural Route address) Please include Province and Postal Code


Personal Health Number on your Care Card:
Aboriginal Status No Yes
If yes, what is your Status Number?:
Social Insurance Number:
Marital Status Never Married Married
Separated Divorced
Widowed
If married, widowed, separated or divorced give full name of spouse. Include Maiden Name if applicable
Your Occupation:
Type of Business or Industry:
Birthday:    Year 
Birthplace. Province and Country:
FATHER'S NAME: Example: Jones, Michael Robert
Father's Birthplace: Example: Kamloops, BC, Canada
MOTHER'S MAIDEN NAME: Example: White, Mary, Lillian
Mother's Birthplace: Example: Regina, Sask., Canada
Physician Information:
Name:  Phone: 
Address:  Postal Code: 
Next of Kin or Executor:
Name:  Phone: 
Address:  Postal Code: 
Relationship to Deceased:
AND / OR: (leave blank if it does not apply)
Other Person to Contact:
Name:  Phone: 
Address:  Postal Code: 
Relationship to Deceased:

Anything You Would Like to Add
Comment




















Call us at 250.701.0001 or Toll Free 1.877.394.0001

You may contact us directly by email at if you prefer.

H. W. Wallace Cremation & Burial Centre,
serving Chemainus, Cobble Hill, Cowichan Bay, Crofton, Duncan, Glenora, Ladysmith,
Lake Cowichan, Maple Bay, Mill Bay North Cowichan, North Oyster, Sahtlam, Saltaire

 
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