Application To Scatter Ashes At Stewart Memorial Square
Canadian Forces Base Borden

Applicant:
  1. Name:__________________________________________________________________________________

  2. Address:________________________________________________________________________________

  3. Telephone:______________________________________________________________________________
Deceased:
  1. Name:__________________________________________________________________________________

  2. Rank On Retirement:______________________Service Number:_________________________

  3. Date Of Death:(Day/Month/Year)__________________________________________________

  4. Regimental Affiliation:___________________________________________________________________

  5. Date Of Enrolment:(Day/Month/Year)_______________________________________________________

  6. Date Of Retirement:(Day/Month/Year)______________________________________________________

  7. Date Of Death:(Day/Month/Year)__________________________________________________________

  8. Decorations And Medals:________________________________________________________________
Ceremony Of Scattering:
  1. Preferred date upon which ashes are to be scattered
    (Or Unspecified)     (Day/Month/Year):_______________________________________________________

  2. Will the ashes be accompanied to CFB Borden:...Yes .../...No... (Circle one)

  3. If Accompanied; By whom:_______________________________________________________________

  4. Is there a requirement for a Chaplain:...Yes.../...No...(Circle one)

  5. Any other pertinent information:__________________________________________________________
    ______________________________________________________________________________________
Memorial
It is desired that the name of the deceased be engraved on a Military Police tablet and that an engraved brass plate (1/2" X 4") bearing the name of the deceased be placed on the wall of the Memorial Chapel of the CFB Borden Military Museum. $210.00 (payable to the CFB Borden Military Museum) is enclosed for this purpose.

Signature:................................