0__ – Deceased or Incapacitated Person Information

'S NAME

2100. First Name

Note: please use the legal first name. Do not use a nickname or the middle name.

2101. Middle Name(s), if any

2102. Last Name

2103. Is known by any other names (eg. name prior to marriage or name on land title)?

a. No (or I do not know)

b. Yes

2113. Where did/does reside?

a. Canada

b. United States of America

c. Other

2116. Mailing Address

2115. City of Town

2117. Postal Code

'S ADDITIONAL INFORMATION

2106. 's Occupation (if retired or not employed, enter ‘Retired’, ‘Homemaker’, ‘Caregiver’, ‘Volunteer’, ‘Unemployed’, or enter the occupation from prior work): *

2118. Date of Birth

2149. Is bankrupt?

a. No

b. Yes

j. I do not know