P.O. Box 207
206 Centre Street
Shaunavon, Saskatchewan
S0N 2M0


Phone: 306-297-2412
Fax: 306-297-2902
Toll Free 1-877-BINKLEY (246-5539)
Email: binkleys@binkleys.com

 

 

Personal Information
* First Name: ________________________________
* Middle Names: ________________________________
* Last Name: ________________________________
* Address: ________________________________
* Town/City: ________________________________
* Province: ________________________________
* Postal Code: ________________________________
  Telephone Number: ________________________________
  Email Address: ________________________________
* Date of Birth: ________________________________
* Place of Birth: 
   (Give Land Numbers
    if Rural)
________________________________
* Marital Status: ________________________________
* Spouses Name:
   (Maiden name and full name 
    of wife or  husbandís full name)
________________________________
* Occupation:
  
(for longest period during 
     working life)
________________________________
  Social Insurance Number: ________________________________ 
* Health Card Number: ________________________________
* Fatherís Full Name: ________________________________
* Fatherís Place of Birth:   
   (Give Land Numbers if Rural)
________________________________
* Motherís Maiden Name: ________________________________
* Motherís Christian Names: ________________________________
* Motherís Place of Birth:   
   (Give Land Numbers if Rural)
________________________________
 

 

Person who will be in charge of my funeral arrangements:


Name: ________________________________
Address: ________________________________
Town/City: ________________________________
Province: ________________________________
Postal Code: ________________________________
Telephone Number: ________________________________

 

Will & Executor


Location of Will: ________________________________
Name: ________________________________
Address: ________________________________
Town/City: ________________________________
Province: ________________________________
Postal Code: ________________________________
Telephone Number: ________________________________

 

Military Information


Veteranís Service Number: ________________________________
Rank ________________________________
Location of Discharge Papers: ________________________________

 

Next of Kin


Spouse:
(Addresses, and phone numbers)
________________________________
________________________________
________________________________
Daughters:
(List their spouses, addresses, and phone numbers)
________________________________
________________________________
________________________________
________________________________
    
Sons:
(List their spouses, addresses, and phone numbers)
________________________________
________________________________
________________________________
________________________________
   
Grandchildren:
(List their spouses, addresses, and phone numbers)
________________________________
________________________________
________________________________
________________________________
   
Sisters:
(List their spouses, addresses, and phone numbers)
________________________________
________________________________
________________________________
________________________________
   
Brothers:
(List their spouses, addresses, and phone numbers)
________________________________
________________________________
________________________________
________________________________
   
Other Relatives:
(List their spouses, addresses, and phone numbers)
________________________________
________________________________
________________________________
________________________________

(If more space is required, please use the back of the form.)

 

 

My Preferences


Place of Service: ________________________________
Clergy: ________________________________

Burial
      Preferred Casket: ________________________________
      Name of Cemetery: ________________________________
      Burial Plot Owned? Yes       No 
      Grave Location ________________________________


Cremation
      Preferred Cremation
      Casket:
________________________________
      Preferred Urn ________________________________
      Final Urn Placement:
      (Burial, Home, Scatter,
       Columbarium
       - Please Describe)
________________________________
________________________________
________________________________
________________________________

Monument, Marker, or Memorial:
(Type, Material and Preferred Inscription)
________________________________
________________________________
________________________________
________________________________

Pallbearers or Honorary Pallbearers: ________________________________
________________________________
________________________________
________________________________
________________________________
________________________________

Lodge, Society, Fraternal Organization:
(List involvement and if you would like an honor guard)
________________________________
________________________________
________________________________
________________________________

Music Selections: ________________________________
________________________________
________________________________
________________________________

Flowers: ________________________________
________________________________
________________________________
________________________________

Memorial Donations: ________________________________
________________________________
________________________________
________________________________

Funeral Service Card:
(Type of design, photo, and verse)
________________________________
________________________________
________________________________
________________________________

Obituary Information:

(List education and place of schooling, wedding date and place, work history and places I lived and worked, Clubs, Lodges, Hobbies, what I liked doing, significant accomplishments, Boards, Committees and community and Church involvement, etc.)

(If more space is needed, 
use the back of the form)

________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
________________________________
 
 
Location of Important Papers:
We all collect important documents and papers. It is essential that numerous items be taken care of. The following items are not part of making funeral arrangements but the information will be very useful for your survivors. You may wish to complete the following list to provide additional assistance to them. If you do not wish to complete this portion at this time it would be helpful for you to make a list on your own at a later date.
 
Please complete in full including the location of each item:
Birth and Marriage Certificates: ________________________________
________________________________

Insurance Policies: ________________________________
________________________________

Bank Accounts and Account Numbers: ________________________________
________________________________
________________________________
________________________________

Stock and Bond Certificates: ________________________________
________________________________
________________________________
________________________________

Automobile Records: ________________________________
________________________________
________________________________
________________________________

Description of property owned:
(List locations and mortgage holders)
________________________________
________________________________
________________________________
________________________________

Retirement Plan and Company Benefits: ________________________________
________________________________
________________________________
________________________________

Safety Deposit Box and location of key: ________________________________
________________________________
________________________________
________________________________

Physicians: ________________________________
________________________________
________________________________
________________________________

Accountant and Attorney:
(List address and telephone numbers)
________________________________
________________________________
________________________________
________________________________

Credit Cards and Numbers: ________________________________
________________________________
________________________________
________________________________

Other Valuables and Benefit entitlements: ________________________________
________________________________
________________________________
________________________________

Any other information or instructions not previously listed: ________________________________
________________________________
________________________________
________________________________

 
 
Please check as many of the following as apply:
Please contact me.
Please forward me a copy of my information for my records.
Please contact me if any of my submitted information needs clarification.
File my information for future reference at Binkleyís Funeral Service (Shaunavon) Ltd.  but Please do not contact me.
I would like to discuss my pre-payment options with no obligation,  please contact me.

Once you have completed the form please forward it to Binkleyís Funeral Service (Shaunavon) Ltd., P.O. Box 207, Shaunavon, SK S0N 2M0 or simply provide a copy for your family.




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