Page 38 - York Cemetery and Funeral Centre
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Vital Statistics
 The information below will be necessary for the preparation of a death certificate. The funeral director will record it and have certified copies made.
........................................................................................................................................Date: ..................................................................................................... My full name: .............................................................................................................................................................................................................................
First Middle Last
Address: .......................................................................................................................................................................................................................................
City Province Country
Birthplace: ...................................................................................................................................................................................................................................
City Province Country
Birth date: .................................................................................................................. Social insurance number: ............................................................. Citizen of what country: ......................................................................................................................................................................................................... Schools attended: .................................................................................................. From: ............................. To: ........................... Degree: .................. .......................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................... Number of years of formal education: ..............................................................................................................................................................................
Professional Statistics
Company: .................................................................................................................. Job title: ........................ From: ..................... To: ............................ .......................................................................................................................................................................................................................................................... .......................................................................................................................................................................................................................................................... Professional achievements: .................................................................................................................................................................................................. .......................................................................................................................................................................................................................................................... Years residence established in this province: ............................................... Years residence established in this community: .................. Marital status: Married Single Divorced Widowed Common Law
Date of marriage: .................................................................................................... Name of Partner: ..............................................................................
Birthplace: ............................................................................................................................................................................Date: .......................................... City Province Country
Name of father: .........................................................................................................................................................................................................................
Birthplace: ............................................................................................................................................................................Date: .......................................... City Province Country
Mother’s maiden name: .........................................................................................................................................................................................................
Birthplace: ............................................................................................................................................................................Date: .......................................... City Province Country
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