Name: Considerate Cremation & Burial Services Inc.
Address: 1-52 Scott Street West, St. Catharines, Ontario, L2R 1C9
Telephone: 289-362-1144

Full Legal Name - First Name:

Middle Name (s):

Last Name:

Please Indicate If There's A Preferred Name That Is Used; Such As Using Middle Name As Primary Name etc:

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Social Insurance Number will be required when services are needed. Please keep this in mind for the future.

Birth Month:

Day of Month:

Year:

City of Birth:

Province/Territory of Birth:

Country of Birth:

Address (include unit #):

City:

Province/Territory:

Postal Code:

Phone Number:

Cell Number:

Email Address:

Occupation: for most of working life - even if retired

Type of Business:

Pacemaker/Defibrillator Implanted?

No

Yes

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Marital Status (please indicate which best reflects current status)

Please indicate:

Single (Never Married)

Married (Separated=Married)

Common Law

Widowed

Divorced (we are still asked to gather former partner's name as per below)

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Marriage Ceritificate / Declaration of Common Law Union

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If Married, please be aware that we will require the Marriage Certificate to assist in applying for the CPP Survivor's Benefit.

If Common Law, please be aware that we will require a Declaration of Common Law Union to assist in applying for the CPP Survivor's Benefit.

Current/Last Partner

Middle(s)

Last (Maiden if Female):

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The following Parent's Information refers to the parents of the person for whom the arrangements are being made.

Father's First Name:

Father's Middle Name(s):

Father's Last Name:

Father's Birth Place:

Mother's First Name:

Mother's Middle Name(s):

Mother's Maiden Name:

Mother's Birth Place:

Is There A Will: (please know that we will ask to see it to verify we are taking direction from the Executor/Executrix)

No

Yes

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If there's a WILL, the Contact Person would be person that's indicated in the WILL as the Executor/Executrix.

Contact Person: First Name

Middle(s)

Last

Is the person, named above, the Executor/Executrix?

Yes

No

Relationship Of Contact Person: (Indicate ALL that apply))

Address (include unit #):

City:

Province/Territory:

Postal Code:

Residence Number:

Cell Number:

Email Address:

Death Notice Information: (please place a (D) after those predeceased)

Memorial Donations To Be Listed In Notice:

Hobbies/Clubs/Activities

Would You Like To Include A Photo With The Notice? We Can Post Photos To Our Web Pages As Well At No Charge.

Yes - with publication of notice in newspaper(s)

Yes - please include on web pages (at no charge)

No

Church Membership:

Lodge/Union Membership:

Other Memberships:

Disposition Options:

Cremation: the cremated remains may be buried in an earth grave or placed in a columbarium wall (niche) at the cemetery or taken home.

Burial: placement of a casket into an earth grave either with or without a grave liner or vault.

Entombment: placement of a casket into mausoleum crypt at the cemetery.

Disposition:

Cremation

Burial

Entombment

Levels Of Service That We Offer:

Traditional Funeral: service with casket present to be followed by either burial or cremation.

Memorial Service: burial or cremation prior to structured service.

Celebration of Life Service: burial or cremation prior to a more casual service.

Memorial Visitation / Celebration of Life: casket/urn may or may not be present (visitation only).

Graveside Service: service at cemetery with either casket or urn.

Immediate Cremation: basic cremation without any type of formal service.

If you have an idea for an option that's not listed above, please advise in the Miscellaneous Notes & Instructions area below and we will certainly assist in any way possible.

The Level Of Service That You Would Like Us To Provide (if unsure please select more than one):

Traditional Funeral

Memorial Service

Celebration of Life Service

Memorial Visitation/Celebration of Life (Visitation Only)

Graveside Service

Immediate Cremation

Do You Own Cemetery Property?

No

Yes - Grave

Yes - Crypt - Mausoleum Wall

Yes - Niche - Columbarium Wall

Name Of Cemetery:

Cemetery City:

Plot Owner:

Miscellaneous Notes & Instructions:

Please Indicate Your Wishes At This Time:

Please hold my personal record on file at this time.

Please provide me with pricing for my preferred service option.

Please contact me to set an appointment to discuss my plans further.

Please contact me as I wish to complete these arrangements by pre-funding.

Preferred Method Of Contact (check all that apply):

Phone

Cell

Email

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Sometimes we are dealing with a family without the knowledge of the person that may be ill; we would never want to create a situation that would be awkward for anyone. If we were to ever have to leave a message we would never say where we are from to avoid the same possible situation. We would simply leave our name only.

If we are to call, please indicate who we should speak with:

The WILL & SIN (Social Insurance Number)

Bring a copy of the Will with you if one exists as we will ask to see it when making arrangements.

Social Insurance Number will be required please call with this when you submit this form.

Please call us, 289-362-1144, when when submitting this form if you are in need of services as a death has occured.

Personal Information Needed For Pre-Arranging:

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