Wall Custance Information – Wall-Custance Funeral Home & Chapel

at need information sheet

We are sorry to hear of your loss.

Step 1: Call us. (519)822-0051 We are here to help you during this difficult time.
Step 2: Fill out this form from the perspective of the person who will be the recipient of the service we provide.
Complete it to the best of your ability and submit what you can. Be sure to include your contact information at the bottom of the form.
Step 3: We will follow up and contact you directly. No prepayment required. Thank you.

Legal First Name

Legal Middle Name

Legal Last Name

Street Address

City/Town

Province

Postal Code

Social Insurance Number

Birthplace

Birth Date

Occupation and Industry (before retirement, if applicable)

Citizenship

Marital Status

Name of Spouse

Maiden Name (if applicable)

Date of Marriage

Father’s Full Name

Father’s Birth Place

Mother’s Maiden and Given Names:

Mother’s Birth Place

Will

YES NO

Location of the Will

Lawyer’s Name

Lawyer’s Phone Number

My Contact Information (person completing form):

Contact Name

Contact Phone Number

Contact Email

Executor(s) and/or Next of Kin: