Janazah/Funeral Vital Statistics – Manitoba Islamic Association

Your Name *

First

Last

Your Email *

Name of decedent (full legal name) *

First

Last

Maiden name of decedent (surname at birth) *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of birth *

Place of birth *

Date of death *

Place of death *

Type of work (when employed)

Place of employment (prior to retirement)

Canadian Social Insurance Number (SIN) *

Marital status *

Name of spouse (if married/widowed) *

Maiden name of spouse *

Name of father *

Birthplace of father *

Name of mother *

Birthplace of mother *

Informant

Informant Name *

First

Last

Informant Relationship *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Next of Kin

Next of kin name *

First

Last

Relationship *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone *

Burial Location *

Glen Lawn Cemetary (455 Lagimodiere Blvd.)
Transcona Cemetary (5014 Dugald Rd.)

Funeral expenses will be paid by *

Family
insurance
EI
Government

Any additional comments