Consent to the disclosure of personal information to a third party

Consent to disclose information to a third party

Funeral Director: Denis Lachance

Deceased Person's Information

Family name at birth *

First name *

Other first names (Separate each first name with a comma)

Gender *

Male
Female

Date of birth *

Date of death

Information about the person reporting the death

Status of the declarant (Responsible person) *

Civil union spouse
Close relative
Ally (relative by marriage)
Other

Last name at birth of the person filing the return *

First name of the declarant *

Home telephone *

Phone (Other number, e.g., cell phone) *

Phone number to use to reach you *

E-mail

purchase. and

Indicate authorized recipients (e.g., notary, lawyer, government agencies, etc.)

Name of the representative *

Company name *

Phone *

Fax

Email address *

Expenses

155 $ + tax — for sending and preparing documents.

125 $ + tax — for opening a file for:

Chrch
Cemetery
Columbarium

Consent to disclose information to a third party

I, the undersigned, authorize Services Funéraires Azur Incinération Inc. to disclose information relating to the death of the deceased named in the form to third parties (notaries, lawyers, banks, government agencies, etc.) for administrative and estate settlement purposes. *

I agree to the transmission of information in accordance with this consent.

Caution!

By clicking on the submit button below, I declare that I have carefully completed this questionnaire.

SANTÉ QUÉBEC
PERMIT

19FUN0007

FUNERAL
DIRECTOR

Denis Lachance

since 1997

Available at all times

Deceased Person's Information

Information about the person reporting the death

Indicate authorized recipients (e.g., notary, lawyer, government agencies, etc.)

Expenses

Consent to disclose information to a third party

Caution!