People - Vital Statistics Agency - Registration of Death

Vital Statistics Agency - Registration of Death
This information must be accurate as it will be submitted for the Registration of Death with the Vital Statistics Agency. If you do not know the answer to any of the questions, please enter "UNKNOWN".

Tip: Please review the questions in this form, and then be sure you have the necessary support documentation at hand, to answer correctly.
Deceased Information
Name*

First NameMiddle NameLast Name
MB Health Number*
Name of Hospital/Home
Date of Death

MonthDayYear
Date
Time of Death

Hour Minutes

AM/PM Option
Date of Birth*

MonthDayYear
Date
Age*
If under one year

MonthsDaysHours/Minutes
Last Residence: Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Never MarriedMarriedWidowedDivorcedSeparatedCommon Law
Name of Spouse/Former Spouse

First NameMiddle NameLast Name
(If deceased) Date of Death of Spouse/Former Spouse

MonthDayYear
Date
Employment Record

OccupationIndustry/Business TypeSIN
Indigenous Identity (if applicable)

Treaty Number and Band NameMetis Registration Number
Place of Birth*

CityProvinceCountry

Vital Statistics Agency - Registration of Death