Vital Statistics

Deceased's Information

Full Legal Name of Deceased*:

Date of Death*:

Gender*:

Place of Death:

Deceased's Address

Address:

City:

Country:

State/Province:

Zip/Postal code:

Date of Birth:

Place of Birth:

Address:

City:

Country:

State/Province:

Zip/Postal code:

Phone:

Occupation*:

if retired, last occupation

Social Insurance Number*:

Martial Status*:

Spouses Full Birth Name:

even if deceasd or divorced

Parental Information

Mother's Full Birth Name:

Mother's Place of Birth:

Address:

City:

Country:

State/Province:

Zip/Postal code:

Phone:

Father's Full Birth Name:

Father's Place of Birth:

Address:

City:

Country:

State/Province:

Zip/Postal code:

Phone:

Next of Kin

Full Legal Name*:

Relationship*:

Executor:

Office use only

FDSD:

Office use only

Invoice:

Address

Address*:

City*:

Country*:

State/Province*:

Zip/Postal code*:

Phone #:

Alt Phone #:

Email*:

Alternate Contact

Full Legal Name*:

Relationship*:

Executor:

Office use only

FDSD:

Office use only

Invoice:

Address

Address*:

City*:

Country*:

State/Province*:

Zip/Postal code*:

Phone #:

Alt Phone #:

Email*:

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Contact Us

2495C Henderson Hwy
East St. Paul
MB R2E 0C2

(Just a few seconds North of the Perimeter on Henderson Hwy)

Tel: (204) 808-4490

Fax: (204) 505-4491

Email: [email protected]

Our Site

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Have a Question?

We understand that there are many questions that arise when a death occurs. We are available 24 hours a day, seven days a week to answer questions you may have and provide direction. Please call us if you require immediate assistance.

Vital Statistics

Step 1

Deceased's Address

Address

Address

Contact Us

(Just a few seconds North of the Perimeter on Henderson Hwy)

Tel: (204) 808-4490

Fax: (204) 505-4491

Email: [email protected]

Our Site

Have a Question?

We understand that there are many questions that arise when a death occurs. We are available 24 hours a day, seven days a week to answer questions you may have and provide direction. Please call us if you require immediate assistance.