Déclaration de décès et requête de crémation

Section 1: Information about the deceased - Step 1 of 6

Creation Date

Price

Declaration of Death (DEC-100, DEC-102).
Funeral Director: Denis Lachance.

IMPORTANT
-Read the general information and instructions that accompany this form.
-Fill in all sections of the form.

At the time of death, what was your relationship with the deceased? *

Spouse
Brother
Sister
Father
Mother
Friend
Other

Specify link *

Section 1: Information about the deceased

Family name at birth *

First name *

Home address

Address Line 1

City

State / Province / Region

Postal Code

Country

To avoid errors, please find your address using the Canada Post tool.

Does the deceased have a pacemaker?

Gender *

Male
Female

Date of birth *

Estimated weight *

Deceased's health insurance number

Social Insurance Number

Place of birth *

Place of birth registration *

Surname of parent at birth

Parent's first name

Last name of other parent at birth

First name of other parent

Place of death

Hospital Center
Palliative care home
CHSLD
Home

Name of facility (e.g. Hôpital Pierre-Le Gardeur ) *

Address of death

Address Line 1

City

State / Province / Region

Postal Code

Country

To avoid errors, please find your address using the Canada Post tool.

Is the deceased still at home? *

Where is the deceased currently in the home?

On which floor is the deceased?

What is the access to reach the deceased?

No stairs, ground-level access
Stairs
Elevator
Access ramp
Other

Approximate number of steps *

Does the access allow passage of a stretcher?

Date of death (if available)

Marital status at time of death *

Single
Married
Widow / Widower
Divorced
Civil union
Former civil union spouse

View the definition of union types on the Registrar of Civil Status website

Section 2: Information about the spouse (or ex-spouse) or civil union spouse (or ex-civil union spouse)

Complete this section if you were married, in a civil union, widowed or divorced, or if your civil union was dissolved.

You have indicated that you are single. Go to section 3.

This section does not apply to you. Press Next to move on to the next section.

to Funéraires the

Family name at birth

First name

(Start with the usual first name, separated by a comma).

Gender

Male
Female

Date of birth

Place of birth

Place of birth registration

Spouse's Social Insurance Number

Place of registration of marriage or civil union

(place of worship, parish, town, village or municipality, province or country).

Date of marriage or civil union

Date of death, divorce or dissolution of civil union

City at time of divorce

Province at time of divorce

Surname at birth (parent)

First name (parent)

Parent's quality

Father
Mother

Last name at birth (other parent)

First name (other parent)

Section 3: Death declarant information

Surname at birth (declarant) *

First name (declarant) *

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

To avoid errors, please find your address using the Canada Post tool.

Home telephone *

Cell phone *

Phone number to use to reach you *

Home telephone

Cell phone

Phone number to use to reach you

Declarer's e-mail address (Responsible for file)

Section 4: Other departments and agencies to be notified of death

Answer the questions below and enter the requested information, if applicable.

Retraite Québec - Public sector pension plans (RREGOP, RRPE or other).

To the best of your knowledge, was the deceased receiving benefits from, or a member of, a public-sector pension plan?

Public Curator of Québec

To the best of your knowledge, was the deceased under protective supervision? If yes, indicate the situation that applied to the deceased.

Multiple choice

She was represented by a mandatary (court-approved mandate in anticipation of incapacity).
She was under tutorship or public curatorship (assumed by the Curateur public du Québec).
She was under guardianship or private curatorship.

To your knowledge, was the deceased the legal representative of an incompetent person?

Multiple choice

Mandataire (court-approved mandate in anticipation of incapacity)
Private tutor or curator

Last name of person represented (if known): *

First name *

Ministère du travail, de l'Emploi et de la Solidarité sociale - Quebec Parental Insurance Plan

To the best of your knowledge, had the deceased filed a claim for Quebec Parental Insurance Plan benefits, or was he or she receiving such benefits because of an upcoming or recent birth or adoption?

Régie du bâtiment du Québec

To the best of your knowledge, was the deceased a building contractor, guarantor or builder-owner licensed by the Régie du bâtiment du Québec?

If you answered Yes, enter the license number.

Aboriginal Affairs and Northern Development Canada

To your knowledge, had the deceased been granted Indian status under the Indian Act by the federal government?

If you answered Yes, please enter the information requested below.

Band number

Band name

Indian registration number

Ministère de la Santé et des Services sociaux - Direction des affaires autochtones II

To your knowledge, had the deceased been recognized as a Cree or Naskapi beneficiary under the Cree-Inuit-Naskapi Native Act by the Government of Quebec?

If you answered Yes, please enter the information requested below.

Affiliate community name

Cree or Naskapi beneficiary number

To your knowledge, did the deceased hold a firearms licence?

If you answered Yes, enter the first eight digits of your firearms licence number below, if known.

Firearms licence number

To your knowledge, did the deceased own one or more firearms?

Ministère de la Sécurité publique - Quebec Firearms Registration Service

To your knowledge, did the deceased own one or more non-restricted firearms registered in the Fichier d'immatriculation des armes à feu du Québec?

Société de l'assurance automobile du Québec

To your knowledge, did the deceased hold a driver's licence issued by the Société de l'assurance automobile du Québec?

If you answered Yes, please enter your driver's license number below.

Driver's license number

Commission des normes, de l'équité, de la santé et de la sécurité du travail

To the best of your knowledge, was the deceased receiving any benefits from the Commission des normes, de l'équité, de la santé et de la sécurité du travail (income replacement benefits, death benefits, drug reimbursement, payment for a hearing aid, home personal assistance allowance, care or treatment, etc.)?

If you answered Yes, enter the deceased's file number below, if known.

File number

Section 5: Cremation request

Did the deceased leave any instructions regarding the mode of disposition? *

Layout, precision

Do you have any objections to cremation of the deceased? *

Does the deceased have a pacemaker? *

Yes
No
Don't know

Add any information you consider relevant here.

Authorization for cremation

I authorize Crématorium des Deux Rives Inc. to proceed with the cremation. *

I agree.

Section 6: Other authorization requests

Personal effects

I understand that personal effects are considered contaminated items. *

I agree.

Transport

By pressing the "Submit" button, I authorize Services Funéraires Azur Incinération Inc. to transport the above-mentioned deceased. *

I agree.

Consent to publication of death notice

By submitting this form, I agree that the digital obituary included in your package will be published on the website and <b>on the social media</b> of Service Funéraire Azur. *

Yes, I accept the publication
No, I refuse publication

Protection of personal information

By checking this box and clicking "Submit", I authorize Services funéraires Azur incinération inc. to collect, use, and disclose the personal information necessary to process my request and provide its services, in accordance with its Personal information protection policy and privacy policy. I also authorize Services funéraires Azur to contact me by email and/or text message (SMS) at the coordinates provided, notably for the follow-up of my request, service-related communications, notices, reminders, and operational notifications. My information may be transmitted to Azur partners when required for the provision of services, including crematoriums, cemeteries, suppliers, carriers, and relevant professionals. Message frequency may vary and message or data rates may apply. I can withdraw my consent to text messages at any time by replying STOP and get help by replying HELP. Consent to receive text messages is not a condition of purchase. *

I agree.

Personal information protection policy and privacy policy

SANTÉ QUÉBEC
PERMIT

19FUN0007

FUNERAL
DIRECTOR

Denis Lachance

since 1997

Available at all times

Section 1: Information about the deceased

Section 2: Information about the spouse (or ex-spouse) or civil union spouse (or ex-civil union spouse)

You have indicated that you are single. Go to section 3.

Section 3: Death declarant information

Section 4: Other departments and agencies to be notified of death

Retraite Québec - Public sector pension plans (RREGOP, RRPE or other).

Public Curator of Québec

Ministère du travail, de l'Emploi et de la Solidarité sociale - Quebec Parental Insurance Plan

Régie du bâtiment du Québec

Aboriginal Affairs and Northern Development Canada

If you answered Yes, please enter the information requested below.

Ministère de la Santé et des Services sociaux - Direction des affaires autochtones II

If you answered Yes, please enter the information requested below.

If you answered Yes, enter the first eight digits of your firearms licence number below, if known.

Ministère de la Sécurité publique - Quebec Firearms Registration Service

Société de l'assurance automobile du Québec

If you answered Yes, please enter your driver's license number below.

Commission des normes, de l'équité, de la santé et de la sécurité du travail

If you answered Yes, enter the deceased's file number below, if known.

Section 5: Cremation request

Authorization for cremation

Section 6: Other authorization requests

Personal effects

Transport

Consent to publication of death notice

Protection of personal information