Pre-Arrangements Form

Northbrook - 11928 Hwy 41
| Northbrook, ON K0H 2G0
| Tel: 1-613-336-6873
| Directions

Parham Chapel - 11014 Road 38
| Parham, ON K0H 2K0
| Tel: 1-613-375-6254
| Directions

Milestone Funeral Homes now offering professional and dignified services from our Northbrook Chapel & Parham Chapel locations

Funeral Establishment Class 1 Operator licensed by the Bereavement Authority of Ontario

Use this form to provide us with as much or as little detail as you wish. At a minimum, provide us with your name and telephone number and tell us how you'd like us to work with you on the remaining information using the options at the base of the form.

Pre-Arrangement Details

Personal Information

Full Name

Street

City

Province

Postal Code (Canada only)

Telephone

Date of Birth

SIN#

Email Address

Place of Birth

Main Occupation Throughout Working Career

Industry

Father's Name

Mother's Name

Mother's Maiden Name

Father's Place of Birth

Mother's Place of Birth

Marital Status

If widowed, provide name only

Spouse's Name

Spouse’s Date of Birth

Spouse's SIN#

Spouse's Maiden Name

Spouse's Place of Birth

Place of Marriage

Date of Marriage

Next of Estate Trustee / Next of Kin Information

Is there a will

YesNo

Full Legal Name

Relationship

Mailing Address

Phone Number

Email Address

Would you like us to contact you?

YesNo

If Yes, add: “How would you like to be contacted?” (Phone / Email)