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Funeral Home Information
Funeral Home Location:
Shawn Jackson Funeral Home
Simplicity London
Simplicity St. Thomas
Funeral Home Registration #:
FE - 594
TS - 1595
Funeral Director Name:
Shawn Jackson
Andrew Slade
Name & Residence
Case ID:
Title:
Mr.
Mrs.
Ms.
Miss
First Name:
Middle Name:
Last Name:
Any Other Names Used:
Last or Single Name at Time of Birth:
Private Residence
Address:
City:
Country:
State/Province:
Zip/Postal code:
Phone Number:
Work or Other Phone Number:
Place of Birth
Date of Birth:
City of Birth:
Province of Birth:
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Other
Country of Birth:
Select
Canada
Other
Social Insurance Number:
Health Card Number:
Version:
Parents
Parent 1 (Father)
Parent 1 First Name:
Parent 1 Middle Name:
Parent 1 Last Name:
City of Birth:
Province of Birth (If Outside of Canada, State the Country):
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Other
Parent 2 (Mother)
Parent 2 First Name:
Parent 2 Middle Name:
Parent 2 Last Name:
Parent 2 Maiden Name:
City of Birth:
Province of Birth (If Outside of Canada, State the Country):
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Other
More Parents Required?
Yes
No
Parent 3 (Step-Father)
Parent 3 First Name:
Parent 3 Middle Name:
Parent 3 Last Name:
City of Birth:
Province of Birth (If Outside of Canada, State the Country):
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Other
Parent 4 (Step-Mother)
Parent 4 First Name:
Parent 4 Middle Name:
Parent 4 Last Name:
Parent 4 Maiden Name:
City of Birth:
Province of Birth (If Outside of Canada, State the Country):
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Other
Occupation
Type of Work Done Most of Working Life:
Type of Business or Industry that the Beneficiary Worked in Most of Working Life:
Company Employed By:
Relationship
Relationship Status:
Single
Married
Widowed
Divorced
Common-law
Same as Private Residence
Spouse First Name:
Spouse Middle Name:
Spouse Last Name:
Spouse Maiden Name:
Address 1:
Address 2:
City
Country
State/Province
Zip/Postal code
Phone:
Date of Birth:
Informant
Title:
Mr.
Mrs.
Ms.
Miss
Same as Parent 1
Same as Parent 2
Same as Spouse
Informant First Name:
Informant Middle Name:
Informant Last Name:
Informant Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
Address 1:
City
Country
State/Province
Zip/Postal code
Phone:
Next of Kin:
Yes
No
Written Communications:
English
French
Verbal Communications:
English
French
Do You Have a Disability:
Yes
No
Do You Require a Second Informant?
Yes
No
Title:
Mr.
Mrs.
Ms.
Miss
Same as Parent 1
Same as Parent 2
Informant First Name:
Informant Middle Name:
Informant Last Name:
Informant Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
Address 1:
City
Country
State/Province
Zip/Postal code
Phone:
Next of Kin:
Yes
No
Written Communications:
English
French
Verbal Communications:
English
French
Executor
Same as Informant
Same as Parent 1
Same as Parent 2
Same as Spouse
Executor First Name:
Executor Middle Name:
Executor Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
Address 1:
Address 2:
City
Country
State/Province
Zip/Postal code
Do You Require a Second Executor?
Yes
No
Same as Parent 1
Same as Parent 2
Executor First Name:
Executor Middle Name:
Executor Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
Address 1:
Address 2:
City
Country
State/Province
Zip/Postal code
Survivors
Same as Informant
Same as Executor
Same as Parent 1
Same as Parent 2
Same as Spouse
Survivor 1 First Name:
Survivor 1 Last Name:
Survivor 1 Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Same as Informant
Same as Executor
Same as Parent 1
Same as Parent 2
Same as Spouse
Survivor 2 First Name:
Survivor 2 Last Name:
Survivor 2 Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Same as Informant
Same as Executor
Same as Parent 1
Same as Parent 2
Same as Spouse
Survivor 3 First Name:
Survivor 3 Last Name:
Survivor 3 Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Same as Informant
Same as Executor
Same as Parent 1
Same as Parent 2
Same as Spouse
Survivor 4 First Name:
Survivor 4 Last Name:
Survivor 4 Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Same as Executor
Same as Parent 1
Same as Parent 2
Same as Informant
Same as Spouse
Survivor 5 First Name:
Survivor 5 Last Name:
Survivor 5 Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 6 First Name:
Survivor 6 Last Name:
Survivor 6 Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 7 First Name:
Survivor 7 Last Name:
Survivor 7 Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 8 First Name:
Survivor 8 Last Name:
Survivor 8 Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 9 First Name:
Survivor 9 Last Name:
Survivor 9 Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 10 First Name:
Survivor 10 Last Name:
Survivor 10 Maiden Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Add More Survivors?
Yes
No
Survivor 11 First Name:
Survivor 11 Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 12 First Name:
Survivor 12 Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 13 First Name:
Survivor 13 Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 14 First Name:
Survivor 14 Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 15 First Name:
Survivor 15 Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Add More Survivors?
Yes
No
Survivor 16 First Name:
Survivor 16 Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 17 First Name:
Survivor 17 Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 18 First Name:
Survivor 18 Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 19 First Name:
Survivor 19 Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
Survivor 20 First Name:
Survivor 20 Last Name:
Relationship:
Father
Step-Father
Father-in-Law
Grandfather
Mother
Step-Mother
Mother-in-Law
Grandmother
Son
Step-Son
Son-in-Law
Grandson
Daughter
Step-Daughter
Daughter-in-Law
GrandDaughter
Brother
Step-Brother
Brother-in-Law
Husband
Wife
Spouse
Sister
Step-Sister
Sister-in-Law
Uncle
Aunt
Nephew
Niece
Cousin
Boyfriend
Girlfriend
Other (please specify)
City
Country
State/Province
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About Us
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Tour the Funeral Home
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About Pre-Planning
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FAQ
Travelling with Cremated Remains
Contact Us
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Home
Obituaries
About Us
Our Staff
Tour the Funeral Home
Testimonials
Our Location
Pre-Planning
About Pre-Planning
Pre-Arrange Online
Pricing
Resources
Aftercare Guide
Grief Resources
Government Resources
FAQ
Travelling with Cremated Remains
Contact Us