Vital Statistics Form | Gilbart Funeral Home | Selkirk MB funeral home and cremation Gimli MB funeral home and cremation

Personal Information

Full name of deceased

Street

City

State/Province

ZIP/Postcode

Occupation

Does the deceased own property?

YesNo

Date of Birth

Place of Birth

SIN #

Date of Death

Place of Death

Age

Sex

Father's Name

Mother's Name

Mother's Maiden Name

Marital Status

Father's Place of Birth

Mother's Place of Birth

Spouse's Name

Place of Marriage

Spouse's Maiden Name

Metis

YesNo

Treaty

YesNo

Band and Treaty #

Funeral Service Request

Place of Service

No Funeral

Place of Visitation

Religious Denomination

Place of Worship

Person in charge of final arrangements

Disposition Request

I Prefer

Cemetery

Lot #(if applicable)

Section/Letter(if applicable)

Grave #(if applicable)

Address

Telephone

Summary Details

Additional instructions for us

Memorial requests or donations to charity

Contact Person

Name

Telephone

Email Address

Street

City

State/Province

ZIP/Postcode

Anti-Spam Security Question