Full name
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Name of the organization
Email address
Phone number
Mailing address
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Information about the deceased
Name of the deceased
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Given name(s) of deceased
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Place of birth of the deceased (City, Province/State, Country)
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Place of death of the deceased (City, Province/State, Country)
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Marital status of the deceased
Single Married Widow(er) Divorced Common-Law Spouse
Name of spouse
Name of deceased spouse
Name of divorced spouse
Spouse's place of birth (City, Province/State, Country)
Place of marriage (City, province/state, country)
Place of Death (City, Province/State, Country)
Place of Death (City, Province/State, Country)
Place of divorce (City, province/state, country)
Information about parents
Father's place of birth (City, Province/State, Country)
Father's place of death (City, Province/State, Country)
Mother's place of birth (City, Province/State, Country)
Mother's place of death (City, Province/State, Country)
Parents' place of marriage (City, Province/State, Country)
If parents were separated and one or both had another spouse, please provide their names.
Information about the immediate family
Birthplace 1 (City, Province/State, Country)
Birthplace 2 (City, Province/State, Country)
Birthplace 3 (City, Province/State, Country)
Birthplace 4 (City, Province/State, Country)
Birthplace 5 (City, Province/State, Country)
If more than 5 siblings, please indicate their name(s) and date(s) of birth in the box.
Information on the paternal line
Birthplace 1 (City, Province/State, Country)
Birthplace 2 (City, Province/State, Country)
Birthplace 3 (City, Province/State, Country)
Birthplace 4 (City, Province/State, Country)
Birthplace 5 (City, Province/State, Country)
Birthplace 6 (City, Province/State, Country)
Place of Birth 7 (City, Province/State, Country)
Birthplace 8 (City, Province/State, Country)
Birthplace 9 (City, Province/State, Country)
Birthplace 10 (City, Province/State, Country)
If more than 10 siblings, please indicate their name(s) and date(s) of birth in the box.
Information on the maternal line
Birthplace 1 (City, Province/State, Country)
Birthplace 2 (City, Province/State, Country)
Birthplace 3 (City, Province/State, Country)
Birthplace 4 (City, Province/State, Country)
Birthplace 5 (City, Province/State, Country)
Birthplace 6 (City, Province/State, Country)
Place of Birth 7 (City, Province/State, Country)
Birthplace 8 (City, Province/State, Country)
Birthplace 9 (City, Province/State, Country)
Birthplace 10 (City, Province/State, Country)
If more than 10 siblings, please indicate their name(s) and date(s) of birth in the box.
Other information that may be useful to us.
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