Pre-Planning
Information

 

 

Complete your information securely online

Pre-Planning Record

Please complete the form below. If you have any questions about any of the information, please do not hesitate to call Charlotte at 250.860.7077 or by email at charlotte@springfieldfuneralhome.com

Full Legal Name

Last Name*

First Name*

Middle Name(s)

Preferred Name / Pronunciation

Gender

 Male     Female     U/K     X

Aboriginal

 Yes 
#
     No   

Live On Reserve

 Yes     No   

 

Card Numbers

Last 3 Digits of BC Care Card #

Last 3 Digits of Social Insurance #

 

Residential Address

Unit

Street Address*

City*

Province*

Postal Code*

Home Phone*

Cellular

Email

 

Marital

Marital Status

Never Married
Separated
Widowed
Married
Divorced
Common-Law

If Married, Common-Law, Separated or Widowed - Full name of Husband or Maiden Name of Wife

Last/Maiden Name

First Name:

 

Spouse's Address

Same As Residential Information Above

Unit

Street Address

City

Province

Postal Code

Home Phone

Cellular

Email

 

Occupation

Occupation Prior To Retirement

Industry

 

Birth

Birth Date (YYYY-MM-DD)*

Birth City

Birth Province / State

Other Birth Province / State

Birth Country

Birth Name (If Different Than Above)

Birth Last Name

Birth First Name

Birth Middle Name(s)

 

 

Father

Last Name

First Name

Middle Name(s)

Birth City

Birth Province / State

Other Birth Province / State

Birth Country

 

Mother

Last Name

First Name

Middle Name(s)

Birth City

Birth Province / State

Other Birth Province / State

Birth Country

 

Person With Legal Right to Control Disposition

Important Notice: All Funeral Providers in the Province of British Columbia, must ensure that decisions concerning Funeral and Disposition arrangements are made by the person who has the Right to Control Disposition. To read who is given the right to control the final disposition and/or funeral arrangements according to the Cremation, Interment and Funeral Service Act of the Province of British Columbia, click here.
 

Last Name

First Name

Relationship

Other Relationship

Address / Contact Same As Applicant

Unit

Street Address

City

Province / State

Other Province / State

Postal / Zip Code

Home Phone

Cellular

Email

 

Burial / Cremation

Burial or Cremation Preference

Burial
Cremation
Not Decided

Cemetery (If Applicable)

Other Cemetery

 

Doctor

Name / Phone

Other Doctor Name / Phone

 

Will

Is There An Estate Will

 Yes     No

 

Contact 1

Same as Spouse
Same as Person with the Right to Control Disposition

Last Name

First Name

Relationship

Other Relationship

Unit

Street Address

City

Province / State

Other Province / State

Postal / Zip Code

Home Phone

Cellular

Email

 

Add Second Contact

Contact 2

Last Name

First Name

Relationship

Other Relationship

Unit

Street Address

City

Province / State

Other Province / State

Postal / Zip Code

Home Phone

Cellular

Email

 

Pre-Planning Funeral Service Instructions

I would like to meet with a Pre-Planning Director to assist in these details

Service Preference

Other Service Preference

Service Location

Other Service Location

Church

Viewing Preference

Prayers

Reception Location

Other Reception Location

Casket Type / Name

Other Casket Type / Name

Urn Prefernce

Other Urn Preferernce

Ministry/Officiant

Obituary Placement (Print/Online)

Please List Obituary Placement Locations

Flowers

Memorial Donations

Music Selections

Other Funeral Service Instructions