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216 Queen Street • Port Perry, ON L9L 1B9
Phone: 905-985-2171 • Toll Free: 1-800-377-9139

Pre-Arrangement Form

One of the advantages of prearranging your own funeral is that it plans for your final wishes prior to the time of need. This removes a huge burden from your family when you take care of the necessary funeral details and you provide all the information that we need. The following form allows you to send us the information we need to complete your prearrangements.
Personal Information
Title:                      
Surname:                      
Given Name(s):                      
Maiden Name:                      
Street Address:                      
City:                      
Region:                      
Province:                      
Country:                      
Postal Code:                      
Phone Number:                      
Email Address:                      
Sex:                      
Social Insurance Number:                      
Birth Information
Date:                      
City:                      
Province:                      
Country:                      
Family Information
Father

Surname, Given Name(s):

  

Birthplace - City, Province, Country:

  
Mother

Maiden Name, Given Name(s):

  

Birthplace -City,Province, Country:

  
Employment Information
Kind of Business:  
Kind of Work:  
Employers Name:  
Employers Address:  
Marital Information
Marital Status:  
Spouse's Title:  
Maiden Name:  
Surname:  
Given Name(s):  
Street:  
City:  
Province:  
Country:  
Postal Code:  
Phone Number:  
Email Address:                      
Next of Kin Information
Surname:  
Given Name(s):  
Street:  
City:  
Province:  
Country:  
Postal Code:  
Phone Number:  
Email Address:                      
Service Information
Church Affiliation:  
Denomination:  
Clergyperson:  

Service - Church, Chapel, Graveside:

  

Visitation -Number of Days:

  
Burial or Cremation:  
Memorial Donations:  
Cemetery:  
Previously Purchased Plot:  
Grave Location:  
Newspaper Information
Newspaper Notice:

 

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216 Queen Street | Port Perry, ON L9L 1B9 | Phone: 905-985-2171 | Fax: 905-985-4572 | Email: director@waggfuneralhome.com