1. Funeral instructions prepared by
Name
*
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Address
*
This funeral arrangement is for:
*
Myself
Someone else
If for someone else, what is your relationship to this person?
These details are required by the registrar in order to provide a death certificate.
Name
*
First Name
Last Name
Maiden name (if applicable)
Gender
*
Male
Female
Date of birth
*
-
Day
-
Month
Year
Date
Place of birth
*
If place of birth is not New Zealand, how long have you lived in New Zealand?
Address
*
Usual Occupation (before retirement)
*
Ethnic Group
*
2. Children's ages
(living children only)
Birth dates of daughter's (please separate each daughter's birth date with a comma)
Birth dates of son's (please separate each son's birth date with a comma)
3. Parents' details
Mother's full name
First Name
Last Name
Maiden Name
Father's full name
First Name
Last Name
Mother's occupation
Father's occupation
4. Marital Status
Status
Married
Never married
Partnered or De Facto
Widowed
Civil union
Separated
Marriage disolved
If married complete the following details:
Spouse's full name
First Name
Last Name
Spouse's maiden name (if applicable)
Spouse's age now
Applicant's age at marriage
Place of marriage
If previously married, complete the following details
Spouse's full name
First Name
Last Name
Spouse's age now
Applicant's age at marriage
Place of marriage
5. Next of kin details / executor of estate
Executor(s)/next of kin
Relationship
Name of solicitor
Address of solicitor
Date of last will
-
Day
-
Month
Year
Date
Will held by
6. Planning the funeral
Thank you for completing the form so far. The information requested from here on is not required by the registrar, but is useful for those organising your funeral service. Please only complete as much as you wish.
Funeral type
Cremation
Burial
If burial, preferred cemetery
If burial, is there an existing plot?
Yes
No
If yes, where?
Plot number
Name associated with the plot
If this is a pre-deceased plot, please give the name
And date
-
Day
-
Month
Year
Date
If cremation, please provide any instructions for the ashes
Name of Funeral Director: Collingwood Funeral Home (Phone 07 347 0069)
Church (please specify)
Other (please specify)
Religious denomination (if any)
Celebrant/Clergy
Hymns to be sung at service?
Yes
No
Favourite Hymns
Music to be played at the service?
Yes
No
Favourite music
Bible Readings, Poems or Literature to be read at the service?
Yes
No
Favourite Readings, Poems or Literature
Were you a member of the Armed Services?
Yes
No
Service number
Overseas/New Zealand Service
Which war?
Unit or regiment
RSA to participate in the funeral?
Yes
No
Favourite flowers, for the casket spray
In lieu of flowers, I would prefer donations to be made to
Viewing
Family only
No viewing
Open viewing
Casket selection
Visit www.westerncaskets.co.nz to see a comprehensive range of caskets.
I would prefer a custom painted casket. My favourite colour is
I would like the funeral/death notice(s) to be in the following papers
I would like the wording for the notice(s) to read
The Funeral Service is to be
Private
Public
Pall bearers will be
Other ideas to make the service personal to me
Refreshments after the Service
Yes
No
7. Other important information
Name of the family doctor
Address of the family doctor
8. Additional information
Any additional information you'd like to provide
Submit
Should be Empty: