Page 19 - Burquitlam Funeral Home

Vital statistics about me:
Name:
Address:
City:
Province:
Social Insurance Number: Date of Birth:
Place of Birth:
Occupation: Employer: Business/Industry: Military Service: Marital Status: Maiden Name:
Name of Spouse: Father’s Name:
His Place of Birth:
Mother’s Name:
Her Place of Birth:
Post Code: Gender:
My preference for the the location of of the the Visitation Service or or Celebration of of Life:
Burquitlam Funeral Home
Place of Worship Address of of place of of worship:
Other
Address of other location:
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