var qsProxy = {};
function FrameBuilder(formId,appendTo,initialHeight,iframeCode,title,embedStyleJSON){this.formId=formId;this.initialHeight=initialHeight;this.iframeCode=iframeCode;this.frame=null;this.timeInterval=200;this.appendTo=appendTo||false;this.formSubmitted=0;this.frameMinWidth='100%';this.defaultHeight='';this.init=function(){this.embedURLHash=this.getMD5(window.location.href);if(embedStyleJSON&&(embedStyleJSON[this.embedURLHash]&&embedStyleJSON[this.embedURLHash]['inlineStyle']['embedWidth'])){this.frameMinWidth=embedStyleJSON[this.embedURLHash]['inlineStyle']['embedWidth']+'px';}
if(embedStyleJSON&&(embedStyleJSON[this.embedURLHash])){if(embedStyleJSON[this.embedURLHash]['inlineStyle']&&embedStyleJSON[this.embedURLHash]['inlineStyle']['embedHeight']){this.defaultHeight='data-frameHeight="'+embedStyleJSON[this.embedURLHash]['inlineStyle']['embedHeight']+'"';}}
this.createFrame();this.addFrameContent(this.iframeCode);};this.createFrame=function(){var tmp_is_ie=!!window.ActiveXObject;this.iframeDomId=document.getElementById(this.formId)?this.formId+'_'+new Date().getTime():this.formId;var htmlCode="<"+"iframe title=\""+title.replace(/[\\"']/g,'\\$&').replace(/&amp;/g,'&')+"\" src=\"\" allowtransparency=\"true\" allow=\"geolocation; microphone; camera\" allowfullscreen=\"true\" name=\""+this.formId+"\" id=\""+this.iframeDomId+"\" style=\"width: 10px; min-width:"+this.frameMinWidth+"; display: block; overflow: hidden; height:"+this.initialHeight+"px; border: none;\" scrolling=\"no\""+this.defaultHeight+"></if"+"rame>";if(this.appendTo===false){document.write(htmlCode);}else{var tmp=document.createElement('div');tmp.innerHTML=htmlCode;var a=this.appendTo;document.getElementById(a).appendChild(tmp.firstChild);}
this.frame=document.getElementById(this.iframeDomId);if(tmp_is_ie===true){try{var iframe=this.frame;var doc=iframe.contentDocument?iframe.contentDocument:(iframe.contentWindow.document||iframe.document);doc.open();doc.write("");}
catch(err){this.frame.src="javascript:void((function(){document.open();document.domain=\'"+this.getBaseDomain()+"\';document.close();})())";}}
this.addEvent(this.frame,'load',this.bindMethod(this.setTimer,this));var self=this;if(window.chrome!==undefined){this.frame.onload=function(){try{var doc=this.contentWindow.document;var _jotform=this.contentWindow.JotForm;if(doc!==undefined){var form=doc.getElementById(""+self.iframeDomId);self.addEvent(form,"submit",function(){if(_jotform.validateAll()){self.formSubmitted=1;}});}}catch(e){}}}};this.addEvent=function(obj,type,fn){if(obj.attachEvent){obj["e"+type+fn]=fn;obj[type+fn]=function(){obj["e"+type+fn](window.event);};obj.attachEvent("on"+type,obj[type+fn]);}
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var iframe=this.frame;var doc=iframe.contentDocument?iframe.contentDocument:(iframe.contentWindow.document||iframe.document);doc.open();doc.write(string);setTimeout(function(){doc.close();try{if('JotFormFrameLoaded'in window){JotFormFrameLoaded();}}catch(e){}},200);};this.setTimer=function(){var self=this;this.interval=setTimeout(this.changeHeight.bind(this),this.timeInterval);};this.getBaseDomain=function(){var thn=window.location.hostname;var cc=0;var buff="";for(var i=0;i<thn.length;i++){var chr=thn.charAt(i);if(chr=="."){cc++;}
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if(cc==2){thn=thn.replace(buff+".","");}
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this.changeHeight=function(){var actualHeight=this.getBodyHeight();var currentHeight=this.getViewPortHeight();if(actualHeight===undefined){this.frame.style.height=this.frameHeight;if(!this.frame.style.minHeight){this.frame.style.minHeight="300px";}}else if(Math.abs(actualHeight-currentHeight)>18){this.frame.style.height=(actualHeight)+"px";}
this.setTimer();};this.bindMethod=function(method,scope){return function(){method.apply(scope,arguments);};};this.frameHeight=0;this.getBodyHeight=function(){if(this.formSubmitted===1){return;}
var height;var scrollHeight;var offsetHeight;try{if(this.frame.contentWindow.document.height){height=this.frame.contentWindow.document.height;if(this.frame.contentWindow.document.body.scrollHeight){height=scrollHeight=this.frame.contentWindow.document.body.scrollHeight;}
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var formWrapper=this.frame.contentWindow.document.querySelector('.form-all');var margin=parseInt(getComputedStyle(formWrapper).marginTop,10);if(!isNaN(margin)){height+=margin;}}}catch(e){}
this.frameHeight=height;return height;};this.getViewPortHeight=function(){if(this.formSubmitted===1){return;}
var height=0;try{if(this.frame.contentWindow.window.innerHeight){height=this.frame.contentWindow.window.innerHeight-18;}else if((this.frame.contentWindow.document.documentElement)&&(this.frame.contentWindow.document.documentElement.clientHeight)){height=this.frame.contentWindow.document.documentElement.clientHeight;}else if((this.frame.contentWindow.document.body)&&(this.frame.contentWindow.document.body.clientHeight)){height=this.frame.contentWindow.document.body.clientHeight;}}catch(e){}
return height;};this.getMD5=function(s){function L(k,d){return(k<<d)|(k>>>(32-d))}function K(G,k){var I,d,F,H,x;F=(G&2147483648);H=(k&2147483648);I=(G&1073741824);d=(k&1073741824);x=(G&1073741823)+(k&1073741823);if(I&d){return(x^2147483648^F^H)}if(I|d){if(x&1073741824){return(x^3221225472^F^H)}else{return(x^1073741824^F^H)}}else{return(x^F^H)}}function r(d,F,k){return(d&F)|((~d)&k)}function q(d,F,k){return(d&k)|(F&(~k))}function p(d,F,k){return(d^F^k)}function n(d,F,k){return(F^(d|(~k)))}function u(G,F,aa,Z,k,H,I){G=K(G,K(K(r(F,aa,Z),k),I));return K(L(G,H),F)}function f(G,F,aa,Z,k,H,I){G=K(G,K(K(q(F,aa,Z),k),I));return K(L(G,H),F)}function D(G,F,aa,Z,k,H,I){G=K(G,K(K(p(F,aa,Z),k),I));return K(L(G,H),F)}function t(G,F,aa,Z,k,H,I){G=K(G,K(K(n(F,aa,Z),k),I));return K(L(G,H),F)}function e(G){var Z;var F=G.length;var x=F+8;var k=(x-(x%64))/64;var I=(k+1)*16;var aa=Array(I-1);var d=0;var H=0;while(H<F){Z=(H-(H%4))/4;d=(H%4)*8;aa[Z]=(aa[Z]|(G.charCodeAt(H)<<d));H++}Z=(H-(H%4))/4;d=(H%4)*8;aa[Z]=aa[Z]|(128<<d);aa[I-2]=F<<3;aa[I-1]=F>>>29;return aa}function B(x){var k="",F="",G,d;for(d=0;d<=3;d++){G=(x>>>(d*8))&255;F="0"+G.toString(16);k=k+F.substr(F.length-2,2)}return k}function J(k){k=k.replace(/rn/g,"n");var d="";for(var F=0;F<k.length;F++){var x=k.charCodeAt(F);if(x<128){d+=String.fromCharCode(x)}else{if((x>127)&&(x<2048)){d+=String.fromCharCode((x>>6)|192);d+=String.fromCharCode((x&63)|128)}else{d+=String.fromCharCode((x>>12)|224);d+=String.fromCharCode(((x>>6)&63)|128);d+=String.fromCharCode((x&63)|128)}}}return d}var C=Array();var P,h,E,v,g,Y,X,W,V;var S=7,Q=12,N=17,M=22;var A=5,z=9,y=14,w=20;var o=4,m=11,l=16,j=23;var U=6,T=10,R=15,O=21;s=J(s);C=e(s);Y=1732584193;X=4023233417;W=2562383102;V=271733878;for(P=0;P<C.length;P+=16){h=Y;E=X;v=W;g=V;Y=u(Y,X,W,V,C[P+0],S,3614090360);V=u(V,Y,X,W,C[P+1],Q,3905402710);W=u(W,V,Y,X,C[P+2],N,606105819);X=u(X,W,V,Y,C[P+3],M,3250441966);Y=u(Y,X,W,V,C[P+4],S,4118548399);V=u(V,Y,X,W,C[P+5],Q,1200080426);W=u(W,V,Y,X,C[P+6],N,2821735955);X=u(X,W,V,Y,C[P+7],M,4249261313);Y=u(Y,X,W,V,C[P+8],S,1770035416);V=u(V,Y,X,W,C[P+9],Q,2336552879);W=u(W,V,Y,X,C[P+10],N,4294925233);X=u(X,W,V,Y,C[P+11],M,2304563134);Y=u(Y,X,W,V,C[P+12],S,1804603682);V=u(V,Y,X,W,C[P+13],Q,4254626195);W=u(W,V,Y,X,C[P+14],N,2792965006);X=u(X,W,V,Y,C[P+15],M,1236535329);Y=f(Y,X,W,V,C[P+1],A,4129170786);V=f(V,Y,X,W,C[P+6],z,3225465664);W=f(W,V,Y,X,C[P+11],y,643717713);X=f(X,W,V,Y,C[P+0],w,3921069994);Y=f(Y,X,W,V,C[P+5],A,3593408605);V=f(V,Y,X,W,C[P+10],z,38016083);W=f(W,V,Y,X,C[P+15],y,3634488961);X=f(X,W,V,Y,C[P+4],w,3889429448);Y=f(Y,X,W,V,C[P+9],A,568446438);V=f(V,Y,X,W,C[P+14],z,3275163606);W=f(W,V,Y,X,C[P+3],y,4107603335);X=f(X,W,V,Y,C[P+8],w,1163531501);Y=f(Y,X,W,V,C[P+13],A,2850285829);V=f(V,Y,X,W,C[P+2],z,4243563512);W=f(W,V,Y,X,C[P+7],y,1735328473);X=f(X,W,V,Y,C[P+12],w,2368359562);Y=D(Y,X,W,V,C[P+5],o,4294588738);V=D(V,Y,X,W,C[P+8],m,2272392833);W=D(W,V,Y,X,C[P+11],l,1839030562);X=D(X,W,V,Y,C[P+14],j,4259657740);Y=D(Y,X,W,V,C[P+1],o,2763975236);V=D(V,Y,X,W,C[P+4],m,1272893353);W=D(W,V,Y,X,C[P+7],l,4139469664);X=D(X,W,V,Y,C[P+10],j,3200236656);Y=D(Y,X,W,V,C[P+13],o,681279174);V=D(V,Y,X,W,C[P+0],m,3936430074);W=D(W,V,Y,X,C[P+3],l,3572445317);X=D(X,W,V,Y,C[P+6],j,76029189);Y=D(Y,X,W,V,C[P+9],o,3654602809);V=D(V,Y,X,W,C[P+12],m,3873151461);W=D(W,V,Y,X,C[P+15],l,530742520);X=D(X,W,V,Y,C[P+2],j,3299628645);Y=t(Y,X,W,V,C[P+0],U,4096336452);V=t(V,Y,X,W,C[P+7],T,1126891415);W=t(W,V,Y,X,C[P+14],R,2878612391);X=t(X,W,V,Y,C[P+5],O,4237533241);Y=t(Y,X,W,V,C[P+12],U,1700485571);V=t(V,Y,X,W,C[P+3],T,2399980690);W=t(W,V,Y,X,C[P+10],R,4293915773);X=t(X,W,V,Y,C[P+1],O,2240044497);Y=t(Y,X,W,V,C[P+8],U,1873313359);V=t(V,Y,X,W,C[P+15],T,4264355552);W=t(W,V,Y,X,C[P+6],R,2734768916);X=t(X,W,V,Y,C[P+13],O,1309151649);Y=t(Y,X,W,V,C[P+4],U,4149444226);V=t(V,Y,X,W,C[P+11],T,3174756917);W=t(W,V,Y,X,C[P+2],R,718787259);X=t(X,W,V,Y,C[P+9],O,3951481745);Y=K(Y,h);X=K(X,E);W=K(W,v);V=K(V,g)}var i=B(Y)+B(X)+B(W)+B(V);return i.toLowerCase()};this.init();}
FrameBuilder.get=qsProxy||[];var i92196291992874=new FrameBuilder("92196291992874",false,"","<!DOCTYPE HTML PUBLIC \"-\/\/W3C\/\/DTD HTML 4.01\/\/EN\" \"http:\/\/www.w3.org\/TR\/html4\/strict.dtd\">\n<html class=\"supernova\"><head>\n<meta http-equiv=\"Content-Type\" content=\"text\/html; charset=utf-8\" \/>\n<link rel=\"alternate\" type=\"application\/json+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=json&amp;url=http%3A%2F%2Fwww.jotform.com%2Fform%2F92196291992874\" title=\"oEmbed Form\"><link rel=\"alternate\" type=\"text\/xml+oembed\" href=\"https:\/\/www.jotform.com\/oembed\/?format=xml&amp;url=http%3A%2F%2Fwww.jotform.com%2Fform%2F92196291992874\" title=\"oEmbed Form\">\n<meta property=\"og:title\" content=\"TGFS Essential Care application form\" >\n<meta property=\"og:url\" content=\"https:\/\/form.jotform.co\/92196291992874\" >\n<meta property=\"og:description\" content=\"Please click the link to complete this form.\">\n<meta name=\"slack-app-id\" content=\"AHNMASS8M\">\n<link rel=\"shortcut icon\" href=\"https:\/\/cdn.jotfor.ms\/favicon.ico\">\n<link rel=\"canonical\" href=\"https:\/\/form.jotform.co\/92196291992874\" \/>\n<meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0, maximum-scale=2.0, user-scalable=1\" \/>\n<meta name=\"HandheldFriendly\" content=\"true\" \/>\n<title>TGFS Essential Care application form<\/title>\n<link href=\"https:\/\/cdn.jotfor.ms\/static\/formCss.css?3.3.13909\" rel=\"stylesheet\" type=\"text\/css\" \/>\n<link type=\"text\/css\" media=\"print\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/printForm.css?3.3.13909\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/css\/styles\/nova.css?3.3.13909\" \/>\n<link type=\"text\/css\" rel=\"stylesheet\" href=\"https:\/\/cdn.jotfor.ms\/themes\/CSS\/566a91c2977cdfcd478b4567.css?themeRevisionID=59fb4852cf3bfe589c6c6f21\"\/>\n<style type=\"text\/css\">\n    .form-label-left{\n        width:75px;\n    }\n    .form-line{\n        padding-top:12px;\n        padding-bottom:12px;\n    }\n    .form-label-right{\n        width:75px;\n    }\n    body, html{\n        margin:0;\n        padding:0;\n        background:#fff;\n    }\n\n    .form-all{\n        margin:0px auto;\n        padding-top:0px;\n        width:590px;\n        color:#555 !important;\n        font-family:\"Lucida Grande\", \"Lucida Sans Unicode\", \"Lucida Sans\", Verdana, sans-serif;\n        font-size:14px;\n    }\n    .form-radio-item label, .form-checkbox-item label, .form-grading-label, .form-header{\n        color: false;\n    }\n\n<\/style>\n\n<style type=\"text\/css\" id=\"form-designer-style\">\n    \/* Injected CSS Code *\/\n.form-label.form-label-auto {\n        \n      display: block;\n      float: none;\n      text-align: left;\n      width: 100%;\n    \n      }\/*PREFERENCES STYLE*\/\n    .form-all {\n      font-family: Lucida Grande, sans-serif;\n    }\n    .form-all .qq-upload-button,\n    .form-all 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type=\"text\/javascript\">\n var jsTime = setInterval(function(){try{\n   JotForm.jsForm = true;\n\n\tJotForm.init(function(){\n      setTimeout(function() {\n          $('input_30').hint('ex: myname@example.com');\n       }, 20);\n\n JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n JotForm.calendarDays = [\"Sunday\",\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"];\n JotForm.calendarOther = {\"today\":\"Today\"};\n var languageOptions = document.querySelectorAll('#langList li'); \n for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) { \n   languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar(\"38\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":true,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"}); }, 0); });\n } \n JotForm.setCalendar(\"38\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":true,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"});\n\n JotForm.calendarMonths = [\"January\",\"February\",\"March\",\"April\",\"May\",\"June\",\"July\",\"August\",\"September\",\"October\",\"November\",\"December\"];\n JotForm.calendarDays = [\"Sunday\",\"Monday\",\"Tuesday\",\"Wednesday\",\"Thursday\",\"Friday\",\"Saturday\",\"Sunday\"];\n JotForm.calendarOther = {\"today\":\"Today\"};\n var languageOptions = document.querySelectorAll('#langList li'); \n for(var langIndex = 0; langIndex < languageOptions.length; langIndex++) { \n   languageOptions[langIndex].on('click', function(e) { setTimeout(function(){ JotForm.setCalendar(\"143\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":true,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"}); }, 0); });\n } \n JotForm.setCalendar(\"143\", false, {\"days\":{\"monday\":true,\"tuesday\":true,\"wednesday\":true,\"thursday\":true,\"friday\":true,\"saturday\":true,\"sunday\":true},\"future\":true,\"past\":true,\"custom\":false,\"ranges\":false,\"start\":\"\",\"end\":\"\"});\n    \/*INIT-END*\/\n\t});\n\n   clearInterval(jsTime);\n }catch(e){}}, 1000);\n\n   JotForm.prepareCalculationsOnTheFly([null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"name\":\"name15\",\"qid\":\"15\",\"text\":\"Name\",\"type\":\"control_fullname\"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"name\":\"email30\",\"qid\":\"30\",\"text\":\"E-mail\",\"type\":\"control_email\"},null,{\"name\":\"personalDetails\",\"qid\":\"32\",\"text\":\"Personal Details\",\"type\":\"control_head\"},null,{\"name\":\"detailsOf\",\"qid\":\"34\",\"text\":\"Details of the deceased\",\"type\":\"control_head\"},{\"description\":\"\",\"name\":\"name\",\"qid\":\"35\",\"text\":\"Name\",\"type\":\"control_fullname\"},{\"description\":\"\",\"name\":\"knownAs\",\"qid\":\"36\",\"subLabel\":\"\",\"text\":\"Known as\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"gender\",\"qid\":\"37\",\"text\":\"Gender\",\"type\":\"control_radio\"},{\"description\":\"\",\"name\":\"dateOf\",\"qid\":\"38\",\"text\":\"Date of 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Relationship\",\"type\":\"control_head\"},null,{\"name\":\"input60\",\"qid\":\"60\",\"text\":\"\",\"type\":\"control_head\"},{\"name\":\"submit\",\"qid\":\"61\",\"text\":\"Submit\",\"type\":\"control_button\"},{\"description\":\"\",\"name\":\"spousepartnersFull\",\"qid\":\"62\",\"text\":\"Spouse\\u002FPartners Full Name\",\"type\":\"control_fullname\"},{\"description\":\"\",\"name\":\"spousepartnerMaiden\",\"qid\":\"63\",\"subLabel\":\"\",\"text\":\"Spouse\\u002FPartner maiden name (if applicable)\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"spousepartnerDate\",\"qid\":\"64\",\"subLabel\":\"\",\"text\":\"Spouse\\u002FPartner date of birth\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"ageAt\",\"qid\":\"65\",\"subLabel\":\"Please enter a number between 0-120\",\"text\":\"Age at time of marriage\\u002Fcivil union\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"placeOf66\",\"qid\":\"66\",\"subLabel\":\"\",\"text\":\"Place of marriage\\u002Fcivil union\",\"type\":\"control_textbox\"},{\"name\":\"input67\",\"qid\":\"67\",\"text\":\"\",\"type\":\"control_head\"},null,null,null,null,{\"name\":\"nextOf\",\"qid\":\"72\",\"text\":\"Next of kin details \\u002F executor of estate\",\"type\":\"control_head\"},{\"description\":\"\",\"name\":\"executorsnextOf\",\"qid\":\"73\",\"subLabel\":\"\",\"text\":\"Executor(s)\\u002Fnext of kin\",\"type\":\"control_textbox\"},{\"description\":\"\",\"name\":\"relationship\",\"qid\":\"74\",\"subLabel\":\"\",\"text\":\"Relationship\",\"type\":\"control_textbox\"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"description\":\"\",\"name\":\"phoneNumber\",\"qid\":\"124\",\"text\":\"Phone Number\",\"type\":\"control_phone\"},{\"description\":\"\",\"name\":\"phoneNumber125\",\"qid\":\"125\",\"text\":\"Phone Number\",\"type\":\"control_phone\"},{\"description\":\"\",\"name\":\"email\",\"qid\":\"126\",\"subLabel\":\"example@example.com\",\"text\":\"Email\",\"type\":\"control_email\"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"description\":\"\",\"name\":\"dateOf143\",\"qid\":\"143\",\"text\":\"Date of marriage\\u002Fcivil union\",\"type\":\"control_datetime\"},null,null,null,null,null,null,null,null,null,null,null,{\"description\":\"\",\"name\":\"residence\",\"qid\":\"155\",\"text\":\"Residence\",\"type\":\"control_address\"},{\"description\":\"\",\"name\":\"address\",\"qid\":\"156\",\"text\":\"Address\",\"type\":\"control_address\"},{\"description\":\"\",\"name\":\"surnameAt\",\"qid\":\"157\",\"subLabel\":\"\",\"text\":\"Surname at 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Payment Options available are:\",\"type\":\"control_radio\"},{\"name\":\"clickTo\",\"qid\":\"166\",\"text\":\"Our terms of trade are payment in full at the time of the removal. We can be contacted on 07 543 1977 at anytime.\\n&nbsp;\\nEssential Care*Price: $ 1,750.00\\nTotal$ 1,750.00\",\"type\":\"control_text\"},{\"description\":\"\",\"name\":\"termsAnd\",\"qid\":\"167\",\"text\":\"Terms and Conditions (please select all)\",\"type\":\"control_checkbox\"},{\"name\":\"clickTo168\",\"qid\":\"168\",\"text\":\"After you submit the above form please contact us on (07) 543 1977 to confirm that we have received your information and we will talk your through the rest of the process.\",\"type\":\"control_text\"},{\"description\":\"\",\"name\":\"relationshipStatus169\",\"qid\":\"169\",\"subLabel\":\"\",\"text\":\"Relationship status at time of death\",\"type\":\"control_dropdown\"},{\"description\":\"\",\"name\":\"mothersName\",\"qid\":\"170\",\"text\":\"Mother's name at birth, if different\",\"type\":\"control_fullname\"},{\"description\":\"\",\"name\":\"mothersName171\",\"qid\":\"171\",\"text\":\"Father's name at birth, if different\",\"type\":\"control_fullname\"},{\"name\":\"typeA\",\"qid\":\"172\",\"text\":\"\",\"type\":\"control_widget\"}]);\n   setTimeout(function() {\nJotForm.paymentExtrasOnTheFly([null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"name\":\"name15\",\"qid\":\"15\",\"text\":\"Name\",\"type\":\"control_fullname\"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,{\"name\":\"email30\",\"qid\":\"30\",\"text\":\"E-mail\",\"type\":\"control_email\"},null,{\"name\":\"personalDetails\",\"qid\":\"32\",\"text\":\"Personal Details\",\"type\":\"control_head\"},null,{\"name\":\"detailsOf\",\"qid\":\"34\",\"text\":\"Details of the deceased\",\"type\":\"control_head\"},{\"description\":\"\",\"name\":\"name\",\"qid\":\"35\",\"text\":\"Name\",\"type\":\"control_fullname\"},{\"description\":\"\",\"name\":\"knownAs\",\"qid\":\"36\",\"subLabel\":\"\",\"text\":\"Known 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different\",\"type\":\"control_fullname\"},{\"name\":\"typeA\",\"qid\":\"172\",\"text\":\"\",\"type\":\"control_widget\"}]);}, 20); \n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" action=\"https:\/\/submit.jotform.co\/submit\/92196291992874\/\" method=\"post\" name=\"form_92196291992874\" id=\"92196291992874\" accept-charset=\"utf-8\">\n  <input type=\"hidden\" name=\"formID\" value=\"92196291992874\" \/>\n  <input type=\"hidden\" id=\"JWTContainer\" value=\"\" \/>\n  <input type=\"hidden\" id=\"cardinalOrderNumber\" value=\"\" \/>\n  <div role=\"main\" class=\"form-all\">\n    <ul class=\"form-section page-section\">\n      <li id=\"cid_32\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h3 id=\"header_32\" class=\"form-header\" data-component=\"header\">\n              Personal Details\n            <\/h3>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_15\">\n        <label class=\"form-label form-label-top\" id=\"label_15\" for=\"first_15\">\n          Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_15\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_15\" name=\"q15_name15[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_15 sublabel_15_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_15\" id=\"sublabel_15_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_15\" name=\"q15_name15[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_15 sublabel_15_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_15\" id=\"sublabel_15_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_email\" id=\"id_30\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_30\" for=\"input_30\">\n          E-mail\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_30\" class=\"form-input-wide jf-required\">\n          <input type=\"email\" id=\"input_30\" name=\"q30_email30\" class=\"form-textbox validate[required, Email]\" size=\"32\" value=\"\" placeholder=\"ex: myname@example.com\" data-component=\"email\" aria-labelledby=\"label_30\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_124\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_124\" for=\"input_124_area\">\n          Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_124\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_124_area\" name=\"q124_phoneNumber[area]\" class=\"form-textbox validate[required]\" size=\"6\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_124 sublabel_124_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_124_area\" id=\"sublabel_124_area\" style=\"min-height:13px\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_124_phone\" name=\"q124_phoneNumber[phone]\" class=\"form-textbox validate[required]\" size=\"12\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_124 sublabel_124_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_124_phone\" id=\"sublabel_124_phone\" style=\"min-height:13px\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_address\" id=\"id_156\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_156\" for=\"input_156_addr_line1\">\n          Address\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_156\" class=\"form-input-wide jf-required\">\n          <table summary=\"\" class=\"form-address-table\">\n            <tbody>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_156_addr_line1\" name=\"q156_address[addr_line1]\" class=\"form-textbox validate[required] form-address-line\" autoComplete=\"address-line1\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_156 sublabel_156_addr_line1\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_156_addr_line1\" id=\"sublabel_156_addr_line1\" style=\"min-height:13px\"> Street Address <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_156_addr_line2\" name=\"q156_address[addr_line2]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line2\" size=\"46\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_156 sublabel_156_addr_line2\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_156_addr_line2\" id=\"sublabel_156_addr_line2\" style=\"min-height:13px\"> Street Address Line 2 <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_156_city\" name=\"q156_address[city]\" class=\"form-textbox validate[required] form-address-city\" autoComplete=\"address-level2\" size=\"21\" value=\"\" data-component=\"city\" aria-labelledby=\"label_156 sublabel_156_city\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_156_city\" id=\"sublabel_156_city\" style=\"min-height:13px\"> City <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_156_state\" name=\"q156_address[state]\" class=\"form-textbox validate[required] form-address-state\" autoComplete=\"address-level1\" size=\"22\" value=\"\" data-component=\"state\" aria-labelledby=\"label_156 sublabel_156_state\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_156_state\" id=\"sublabel_156_state\" style=\"min-height:13px\"> State \/ Province <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_156_postal\" name=\"q156_address[postal]\" class=\"form-textbox form-address-postal\" autoComplete=\"postal-code\" size=\"10\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_156 sublabel_156_postal\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_156_postal\" id=\"sublabel_156_postal\" style=\"min-height:13px\"> Postal \/ Zip Code <\/label>\n                  <\/span>\n                <\/td>\n                <td style=\"display:none\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <select class=\"form-dropdown validate[required] form-address-country noTranslate\" name=\"q156_address[country]\" id=\"input_156_country\" data-component=\"country\" required=\"\" aria-labelledby=\"label_156 sublabel_156_country\" autoComplete=\"new-password\">\n                      <option value=\"\"> Please Select <\/option>\n                      <option value=\"United States\"> United States <\/option>\n                      <option value=\"Afghanistan\"> Afghanistan <\/option>\n                      <option value=\"Albania\"> Albania <\/option>\n                      <option value=\"Algeria\"> Algeria <\/option>\n                      <option value=\"American Samoa\"> American Samoa <\/option>\n                      <option value=\"Andorra\"> Andorra <\/option>\n                      <option value=\"Angola\"> Angola <\/option>\n                      <option value=\"Anguilla\"> Anguilla <\/option>\n                      <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                      <option value=\"Argentina\"> Argentina <\/option>\n                      <option value=\"Armenia\"> Armenia <\/option>\n                      <option value=\"Aruba\"> Aruba <\/option>\n                      <option value=\"Australia\"> Australia <\/option>\n                      <option value=\"Austria\"> Austria <\/option>\n                      <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                      <option value=\"The Bahamas\"> The Bahamas <\/option>\n                      <option value=\"Bahrain\"> Bahrain <\/option>\n                      <option value=\"Bangladesh\"> Bangladesh <\/option>\n                      <option value=\"Barbados\"> Barbados <\/option>\n                      <option value=\"Belarus\"> Belarus <\/option>\n                      <option value=\"Belgium\"> Belgium <\/option>\n                      <option value=\"Belize\"> Belize <\/option>\n                      <option value=\"Benin\"> Benin <\/option>\n                      <option value=\"Bermuda\"> Bermuda <\/option>\n                      <option value=\"Bhutan\"> Bhutan <\/option>\n                      <option value=\"Bolivia\"> Bolivia <\/option>\n                      <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                      <option value=\"Botswana\"> Botswana <\/option>\n                      <option value=\"Brazil\"> Brazil <\/option>\n                      <option value=\"Brunei\"> Brunei <\/option>\n                      <option value=\"Bulgaria\"> Bulgaria <\/option>\n                      <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                      <option value=\"Burundi\"> Burundi <\/option>\n                      <option value=\"Cambodia\"> Cambodia <\/option>\n                      <option value=\"Cameroon\"> Cameroon <\/option>\n                      <option value=\"Canada\"> Canada <\/option>\n                      <option value=\"Cape Verde\"> Cape Verde <\/option>\n                      <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                      <option value=\"Central African Republic\"> Central African Republic <\/option>\n                      <option value=\"Chad\"> Chad <\/option>\n                      <option value=\"Chile\"> Chile <\/option>\n                      <option value=\"China\"> China <\/option>\n                      <option value=\"Christmas Island\"> Christmas Island <\/option>\n                      <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                      <option value=\"Colombia\"> Colombia <\/option>\n                      <option value=\"Comoros\"> Comoros <\/option>\n                      <option value=\"Congo\"> Congo <\/option>\n                      <option value=\"Cook Islands\"> Cook Islands <\/option>\n                      <option value=\"Costa Rica\"> Costa Rica <\/option>\n                      <option value=\"Cote d&#x27;Ivoire\"> Cote d&#x27;Ivoire <\/option>\n                      <option value=\"Croatia\"> Croatia <\/option>\n                      <option value=\"Cuba\"> Cuba <\/option>\n                      <option value=\"Cyprus\"> Cyprus <\/option>\n                      <option value=\"Czech Republic\"> Czech Republic <\/option>\n                      <option value=\"Democratic Republic of the Congo\"> Democratic Republic of the Congo <\/option>\n                      <option value=\"Denmark\"> Denmark <\/option>\n                      <option value=\"Djibouti\"> Djibouti <\/option>\n                      <option value=\"Dominica\"> Dominica <\/option>\n                      <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                      <option value=\"Ecuador\"> Ecuador <\/option>\n                      <option value=\"Egypt\"> Egypt <\/option>\n                      <option value=\"El Salvador\"> El Salvador <\/option>\n                      <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                      <option value=\"Eritrea\"> Eritrea <\/option>\n                      <option value=\"Estonia\"> Estonia <\/option>\n                      <option value=\"Ethiopia\"> Ethiopia <\/option>\n                      <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                      <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                      <option value=\"Fiji\"> Fiji <\/option>\n                      <option value=\"Finland\"> Finland <\/option>\n                      <option value=\"France\"> France <\/option>\n                      <option value=\"French Polynesia\"> French Polynesia <\/option>\n                      <option value=\"Gabon\"> Gabon <\/option>\n                      <option value=\"The Gambia\"> The Gambia <\/option>\n                      <option value=\"Georgia\"> Georgia <\/option>\n                      <option value=\"Germany\"> Germany <\/option>\n                      <option value=\"Ghana\"> Ghana <\/option>\n                      <option value=\"Gibraltar\"> Gibraltar <\/option>\n                      <option value=\"Greece\"> Greece <\/option>\n                      <option value=\"Greenland\"> Greenland <\/option>\n                      <option value=\"Grenada\"> Grenada <\/option>\n                      <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                      <option value=\"Guam\"> Guam <\/option>\n                      <option value=\"Guatemala\"> Guatemala <\/option>\n                      <option value=\"Guernsey\"> Guernsey <\/option>\n                      <option value=\"Guinea\"> Guinea <\/option>\n                      <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                      <option value=\"Guyana\"> Guyana <\/option>\n                      <option value=\"Haiti\"> Haiti <\/option>\n                      <option value=\"Honduras\"> Honduras <\/option>\n                      <option value=\"Hong Kong\"> Hong Kong <\/option>\n                      <option value=\"Hungary\"> Hungary <\/option>\n                      <option value=\"Iceland\"> Iceland <\/option>\n                      <option value=\"India\"> India <\/option>\n                      <option value=\"Indonesia\"> Indonesia <\/option>\n                      <option value=\"Iran\"> Iran <\/option>\n                      <option value=\"Iraq\"> Iraq <\/option>\n                      <option value=\"Ireland\"> Ireland <\/option>\n                      <option value=\"Israel\"> Israel <\/option>\n                      <option value=\"Italy\"> Italy <\/option>\n                      <option value=\"Jamaica\"> Jamaica <\/option>\n                      <option value=\"Japan\"> Japan <\/option>\n                      <option value=\"Jersey\"> Jersey <\/option>\n                      <option value=\"Jordan\"> Jordan <\/option>\n                      <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                      <option value=\"Kenya\"> Kenya <\/option>\n                      <option value=\"Kiribati\"> Kiribati <\/option>\n                      <option value=\"North Korea\"> North Korea <\/option>\n                      <option value=\"South Korea\"> South Korea <\/option>\n                      <option value=\"Kosovo\"> Kosovo <\/option>\n                      <option value=\"Kuwait\"> Kuwait <\/option>\n                      <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                      <option value=\"Laos\"> Laos <\/option>\n                      <option value=\"Latvia\"> Latvia <\/option>\n                      <option value=\"Lebanon\"> Lebanon <\/option>\n                      <option value=\"Lesotho\"> Lesotho <\/option>\n                      <option value=\"Liberia\"> Liberia <\/option>\n                      <option value=\"Libya\"> Libya <\/option>\n                      <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                      <option value=\"Lithuania\"> Lithuania <\/option>\n                      <option value=\"Luxembourg\"> Luxembourg <\/option>\n                      <option value=\"Macau\"> Macau <\/option>\n                      <option value=\"Macedonia\"> Macedonia <\/option>\n                      <option value=\"Madagascar\"> Madagascar <\/option>\n                      <option value=\"Malawi\"> Malawi <\/option>\n                      <option value=\"Malaysia\"> Malaysia <\/option>\n                      <option value=\"Maldives\"> Maldives <\/option>\n                      <option value=\"Mali\"> Mali <\/option>\n                      <option value=\"Malta\"> Malta <\/option>\n                      <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                      <option value=\"Martinique\"> Martinique <\/option>\n                      <option value=\"Mauritania\"> Mauritania <\/option>\n                      <option value=\"Mauritius\"> Mauritius <\/option>\n                      <option value=\"Mayotte\"> Mayotte <\/option>\n                      <option value=\"Mexico\"> Mexico <\/option>\n                      <option value=\"Micronesia\"> Micronesia <\/option>\n                      <option value=\"Moldova\"> Moldova <\/option>\n                      <option value=\"Monaco\"> Monaco <\/option>\n                      <option value=\"Mongolia\"> Mongolia <\/option>\n                      <option value=\"Montenegro\"> Montenegro <\/option>\n                      <option value=\"Montserrat\"> Montserrat <\/option>\n                      <option value=\"Morocco\"> Morocco <\/option>\n                      <option value=\"Mozambique\"> Mozambique <\/option>\n                      <option value=\"Myanmar\"> Myanmar <\/option>\n                      <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                      <option value=\"Namibia\"> Namibia <\/option>\n                      <option value=\"Nauru\"> Nauru <\/option>\n                      <option value=\"Nepal\"> Nepal <\/option>\n                      <option value=\"Netherlands\"> Netherlands <\/option>\n                      <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                      <option value=\"New Caledonia\"> New Caledonia <\/option>\n                      <option value=\"New Zealand\"> New Zealand <\/option>\n                      <option value=\"Nicaragua\"> Nicaragua <\/option>\n                      <option value=\"Niger\"> Niger <\/option>\n                      <option value=\"Nigeria\"> Nigeria <\/option>\n                      <option value=\"Niue\"> Niue <\/option>\n                      <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                      <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                      <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                      <option value=\"Norway\"> Norway <\/option>\n                      <option value=\"Oman\"> Oman <\/option>\n                      <option value=\"Pakistan\"> Pakistan <\/option>\n                      <option value=\"Palau\"> Palau <\/option>\n                      <option value=\"Palestine\"> Palestine <\/option>\n                      <option value=\"Panama\"> Panama <\/option>\n                      <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                      <option value=\"Paraguay\"> Paraguay <\/option>\n                      <option value=\"Peru\"> Peru <\/option>\n                      <option value=\"Philippines\"> Philippines <\/option>\n                      <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                      <option value=\"Poland\"> Poland <\/option>\n                      <option value=\"Portugal\"> Portugal <\/option>\n                      <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                      <option value=\"Qatar\"> Qatar <\/option>\n                      <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n                      <option value=\"Romania\"> Romania <\/option>\n                      <option value=\"Russia\"> Russia <\/option>\n                      <option value=\"Rwanda\"> Rwanda <\/option>\n                      <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                      <option value=\"Saint Helena\"> Saint Helena <\/option>\n                      <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                      <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                      <option value=\"Saint Martin\"> Saint Martin <\/option>\n                      <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                      <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                      <option value=\"Samoa\"> Samoa <\/option>\n                      <option value=\"San Marino\"> San Marino <\/option>\n                      <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                      <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                      <option value=\"Senegal\"> Senegal <\/option>\n                      <option value=\"Serbia\"> Serbia <\/option>\n                      <option value=\"Seychelles\"> Seychelles <\/option>\n                      <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                      <option value=\"Singapore\"> Singapore <\/option>\n                      <option value=\"Slovakia\"> Slovakia <\/option>\n                      <option value=\"Slovenia\"> Slovenia <\/option>\n                      <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                      <option value=\"Somalia\"> Somalia <\/option>\n                      <option value=\"Somaliland\"> Somaliland <\/option>\n                      <option value=\"South Africa\"> South Africa <\/option>\n                      <option value=\"South Ossetia\"> South Ossetia <\/option>\n                      <option value=\"South Sudan\"> South Sudan <\/option>\n                      <option value=\"Spain\"> Spain <\/option>\n                      <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                      <option value=\"Sudan\"> Sudan <\/option>\n                      <option value=\"Suriname\"> Suriname <\/option>\n                      <option value=\"Svalbard\"> Svalbard <\/option>\n                      <option value=\"eSwatini\"> eSwatini <\/option>\n                      <option value=\"Sweden\"> Sweden <\/option>\n                      <option value=\"Switzerland\"> Switzerland <\/option>\n                      <option value=\"Syria\"> Syria <\/option>\n                      <option value=\"Taiwan\"> Taiwan <\/option>\n                      <option value=\"Tajikistan\"> Tajikistan <\/option>\n                      <option value=\"Tanzania\"> Tanzania <\/option>\n                      <option value=\"Thailand\"> Thailand <\/option>\n                      <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                      <option value=\"Togo\"> Togo <\/option>\n                      <option value=\"Tokelau\"> Tokelau <\/option>\n                      <option value=\"Tonga\"> Tonga <\/option>\n                      <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                      <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                      <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                      <option value=\"Tunisia\"> Tunisia <\/option>\n                      <option value=\"Turkey\"> Turkey <\/option>\n                      <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                      <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                      <option value=\"Tuvalu\"> Tuvalu <\/option>\n                      <option value=\"Uganda\"> Uganda <\/option>\n                      <option value=\"Ukraine\"> Ukraine <\/option>\n                      <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                      <option value=\"United Kingdom\"> United Kingdom <\/option>\n                      <option value=\"Uruguay\"> Uruguay <\/option>\n                      <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                      <option value=\"Vanuatu\"> Vanuatu <\/option>\n                      <option value=\"Vatican City\"> Vatican City <\/option>\n                      <option value=\"Venezuela\"> Venezuela <\/option>\n                      <option value=\"Vietnam\"> Vietnam <\/option>\n                      <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                      <option value=\"Isle of Man\"> Isle of Man <\/option>\n                      <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                      <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                      <option value=\"Western Sahara\"> Western Sahara <\/option>\n                      <option value=\"Yemen\"> Yemen <\/option>\n                      <option value=\"Zambia\"> Zambia <\/option>\n                      <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                      <option value=\"other\"> Other <\/option>\n                    <\/select>\n                    <label class=\"form-sub-label\" for=\"input_156_country\" id=\"sublabel_156_country\" style=\"min-height:13px\"> Country <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n            <\/tbody>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li id=\"cid_72\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_72\" class=\"form-header\" data-component=\"header\">\n              Next of kin details \/ executor of estate\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_73\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_73\" for=\"input_73\">\n          Executor(s)\/next of kin\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_73\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_73\" name=\"q73_executorsnextOf\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_73\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_74\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_74\" for=\"input_74\">\n          Relationship\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_74\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_74\" name=\"q74_relationship\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_74\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_email\" id=\"id_126\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_126\" for=\"input_126\">\n          Email\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_126\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n            <input type=\"email\" id=\"input_126\" name=\"q126_email\" class=\"form-textbox validate[required, Email]\" size=\"30\" value=\"\" data-component=\"email\" aria-labelledby=\"label_126 sublabel_input_126\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_126\" id=\"sublabel_input_126\" style=\"min-height:13px\"> example@example.com <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_phone\" id=\"id_125\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_125\" for=\"input_125_area\">\n          Phone Number\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_125\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_125_area\" name=\"q125_phoneNumber125[area]\" class=\"form-textbox validate[required]\" size=\"6\" value=\"\" data-component=\"areaCode\" aria-labelledby=\"label_125 sublabel_125_area\" required=\"\" \/>\n              <span class=\"phone-separate\" aria-hidden=\"true\">\n                \u00a0-\n              <\/span>\n              <label class=\"form-sub-label\" for=\"input_125_area\" id=\"sublabel_125_area\" style=\"min-height:13px\"> Area Code <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"tel\" id=\"input_125_phone\" name=\"q125_phoneNumber125[phone]\" class=\"form-textbox validate[required]\" size=\"12\" value=\"\" data-component=\"phone\" aria-labelledby=\"label_125 sublabel_125_phone\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"input_125_phone\" id=\"sublabel_125_phone\" style=\"min-height:13px\"> Phone Number <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_34\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_34\" class=\"form-header\" data-component=\"header\">\n              Details of the deceased\n            <\/h2>\n            <div id=\"subHeader_34\" class=\"form-subHeader\">\n              These details are required by the registrar in order to provide a death certificate.\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_35\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_35\" for=\"first_35\">\n          Name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_35\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_35\" name=\"q35_name[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_35 sublabel_35_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_35\" id=\"sublabel_35_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_35\" name=\"q35_name[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_35 sublabel_35_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_35\" id=\"sublabel_35_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_36\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_36\" for=\"input_36\"> Known as <\/label>\n        <div id=\"cid_36\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_36\" name=\"q36_knownAs\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_36\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_address\" id=\"id_155\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_155\" for=\"input_155_addr_line1\">\n          Residence\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_155\" class=\"form-input-wide jf-required\">\n          <table summary=\"\" class=\"form-address-table\">\n            <tbody>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_155_addr_line1\" name=\"q155_residence[addr_line1]\" class=\"form-textbox validate[required] form-address-line\" autoComplete=\"address-line1\" value=\"\" data-component=\"address_line_1\" aria-labelledby=\"label_155 sublabel_155_addr_line1\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_155_addr_line1\" id=\"sublabel_155_addr_line1\" style=\"min-height:13px\"> Street Address <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td colSpan=\"2\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_155_addr_line2\" name=\"q155_residence[addr_line2]\" class=\"form-textbox form-address-line\" autoComplete=\"address-line2\" size=\"46\" value=\"\" data-component=\"address_line_2\" aria-labelledby=\"label_155 sublabel_155_addr_line2\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_155_addr_line2\" id=\"sublabel_155_addr_line2\" style=\"min-height:13px\"> Street Address Line 2 <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_155_city\" name=\"q155_residence[city]\" class=\"form-textbox validate[required] form-address-city\" autoComplete=\"address-level2\" size=\"21\" value=\"\" data-component=\"city\" aria-labelledby=\"label_155 sublabel_155_city\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_155_city\" id=\"sublabel_155_city\" style=\"min-height:13px\"> City <\/label>\n                  <\/span>\n                <\/td>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_155_state\" name=\"q155_residence[state]\" class=\"form-textbox validate[required] form-address-state\" autoComplete=\"address-level1\" size=\"22\" value=\"\" data-component=\"state\" aria-labelledby=\"label_155 sublabel_155_state\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_155_state\" id=\"sublabel_155_state\" style=\"min-height:13px\"> State \/ Province <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n              <tr>\n                <td>\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <input type=\"text\" id=\"input_155_postal\" name=\"q155_residence[postal]\" class=\"form-textbox form-address-postal\" autoComplete=\"postal-code\" size=\"10\" value=\"\" data-component=\"zip\" aria-labelledby=\"label_155 sublabel_155_postal\" required=\"\" \/>\n                    <label class=\"form-sub-label\" for=\"input_155_postal\" id=\"sublabel_155_postal\" style=\"min-height:13px\"> Postal \/ Zip Code <\/label>\n                  <\/span>\n                <\/td>\n                <td style=\"display:none\">\n                  <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                    <select class=\"form-dropdown validate[required] form-address-country noTranslate\" name=\"q155_residence[country]\" id=\"input_155_country\" data-component=\"country\" required=\"\" aria-labelledby=\"label_155 sublabel_155_country\" autoComplete=\"new-password\">\n                      <option value=\"\"> Please Select <\/option>\n                      <option value=\"United States\"> United States <\/option>\n                      <option value=\"Afghanistan\"> Afghanistan <\/option>\n                      <option value=\"Albania\"> Albania <\/option>\n                      <option value=\"Algeria\"> Algeria <\/option>\n                      <option value=\"American Samoa\"> American Samoa <\/option>\n                      <option value=\"Andorra\"> Andorra <\/option>\n                      <option value=\"Angola\"> Angola <\/option>\n                      <option value=\"Anguilla\"> Anguilla <\/option>\n                      <option value=\"Antigua and Barbuda\"> Antigua and Barbuda <\/option>\n                      <option value=\"Argentina\"> Argentina <\/option>\n                      <option value=\"Armenia\"> Armenia <\/option>\n                      <option value=\"Aruba\"> Aruba <\/option>\n                      <option value=\"Australia\"> Australia <\/option>\n                      <option value=\"Austria\"> Austria <\/option>\n                      <option value=\"Azerbaijan\"> Azerbaijan <\/option>\n                      <option value=\"The Bahamas\"> The Bahamas <\/option>\n                      <option value=\"Bahrain\"> Bahrain <\/option>\n                      <option value=\"Bangladesh\"> Bangladesh <\/option>\n                      <option value=\"Barbados\"> Barbados <\/option>\n                      <option value=\"Belarus\"> Belarus <\/option>\n                      <option value=\"Belgium\"> Belgium <\/option>\n                      <option value=\"Belize\"> Belize <\/option>\n                      <option value=\"Benin\"> Benin <\/option>\n                      <option value=\"Bermuda\"> Bermuda <\/option>\n                      <option value=\"Bhutan\"> Bhutan <\/option>\n                      <option value=\"Bolivia\"> Bolivia <\/option>\n                      <option value=\"Bosnia and Herzegovina\"> Bosnia and Herzegovina <\/option>\n                      <option value=\"Botswana\"> Botswana <\/option>\n                      <option value=\"Brazil\"> Brazil <\/option>\n                      <option value=\"Brunei\"> Brunei <\/option>\n                      <option value=\"Bulgaria\"> Bulgaria <\/option>\n                      <option value=\"Burkina Faso\"> Burkina Faso <\/option>\n                      <option value=\"Burundi\"> Burundi <\/option>\n                      <option value=\"Cambodia\"> Cambodia <\/option>\n                      <option value=\"Cameroon\"> Cameroon <\/option>\n                      <option value=\"Canada\"> Canada <\/option>\n                      <option value=\"Cape Verde\"> Cape Verde <\/option>\n                      <option value=\"Cayman Islands\"> Cayman Islands <\/option>\n                      <option value=\"Central African Republic\"> Central African Republic <\/option>\n                      <option value=\"Chad\"> Chad <\/option>\n                      <option value=\"Chile\"> Chile <\/option>\n                      <option value=\"China\"> China <\/option>\n                      <option value=\"Christmas Island\"> Christmas Island <\/option>\n                      <option value=\"Cocos (Keeling) Islands\"> Cocos (Keeling) Islands <\/option>\n                      <option value=\"Colombia\"> Colombia <\/option>\n                      <option value=\"Comoros\"> Comoros <\/option>\n                      <option value=\"Congo\"> Congo <\/option>\n                      <option value=\"Cook Islands\"> Cook Islands <\/option>\n                      <option value=\"Costa Rica\"> Costa Rica <\/option>\n                      <option value=\"Cote d&#x27;Ivoire\"> Cote d&#x27;Ivoire <\/option>\n                      <option value=\"Croatia\"> Croatia <\/option>\n                      <option value=\"Cuba\"> Cuba <\/option>\n                      <option value=\"Cyprus\"> Cyprus <\/option>\n                      <option value=\"Czech Republic\"> Czech Republic <\/option>\n                      <option value=\"Democratic Republic of the Congo\"> Democratic Republic of the Congo <\/option>\n                      <option value=\"Denmark\"> Denmark <\/option>\n                      <option value=\"Djibouti\"> Djibouti <\/option>\n                      <option value=\"Dominica\"> Dominica <\/option>\n                      <option value=\"Dominican Republic\"> Dominican Republic <\/option>\n                      <option value=\"Ecuador\"> Ecuador <\/option>\n                      <option value=\"Egypt\"> Egypt <\/option>\n                      <option value=\"El Salvador\"> El Salvador <\/option>\n                      <option value=\"Equatorial Guinea\"> Equatorial Guinea <\/option>\n                      <option value=\"Eritrea\"> Eritrea <\/option>\n                      <option value=\"Estonia\"> Estonia <\/option>\n                      <option value=\"Ethiopia\"> Ethiopia <\/option>\n                      <option value=\"Falkland Islands\"> Falkland Islands <\/option>\n                      <option value=\"Faroe Islands\"> Faroe Islands <\/option>\n                      <option value=\"Fiji\"> Fiji <\/option>\n                      <option value=\"Finland\"> Finland <\/option>\n                      <option value=\"France\"> France <\/option>\n                      <option value=\"French Polynesia\"> French Polynesia <\/option>\n                      <option value=\"Gabon\"> Gabon <\/option>\n                      <option value=\"The Gambia\"> The Gambia <\/option>\n                      <option value=\"Georgia\"> Georgia <\/option>\n                      <option value=\"Germany\"> Germany <\/option>\n                      <option value=\"Ghana\"> Ghana <\/option>\n                      <option value=\"Gibraltar\"> Gibraltar <\/option>\n                      <option value=\"Greece\"> Greece <\/option>\n                      <option value=\"Greenland\"> Greenland <\/option>\n                      <option value=\"Grenada\"> Grenada <\/option>\n                      <option value=\"Guadeloupe\"> Guadeloupe <\/option>\n                      <option value=\"Guam\"> Guam <\/option>\n                      <option value=\"Guatemala\"> Guatemala <\/option>\n                      <option value=\"Guernsey\"> Guernsey <\/option>\n                      <option value=\"Guinea\"> Guinea <\/option>\n                      <option value=\"Guinea-Bissau\"> Guinea-Bissau <\/option>\n                      <option value=\"Guyana\"> Guyana <\/option>\n                      <option value=\"Haiti\"> Haiti <\/option>\n                      <option value=\"Honduras\"> Honduras <\/option>\n                      <option value=\"Hong Kong\"> Hong Kong <\/option>\n                      <option value=\"Hungary\"> Hungary <\/option>\n                      <option value=\"Iceland\"> Iceland <\/option>\n                      <option value=\"India\"> India <\/option>\n                      <option value=\"Indonesia\"> Indonesia <\/option>\n                      <option value=\"Iran\"> Iran <\/option>\n                      <option value=\"Iraq\"> Iraq <\/option>\n                      <option value=\"Ireland\"> Ireland <\/option>\n                      <option value=\"Israel\"> Israel <\/option>\n                      <option value=\"Italy\"> Italy <\/option>\n                      <option value=\"Jamaica\"> Jamaica <\/option>\n                      <option value=\"Japan\"> Japan <\/option>\n                      <option value=\"Jersey\"> Jersey <\/option>\n                      <option value=\"Jordan\"> Jordan <\/option>\n                      <option value=\"Kazakhstan\"> Kazakhstan <\/option>\n                      <option value=\"Kenya\"> Kenya <\/option>\n                      <option value=\"Kiribati\"> Kiribati <\/option>\n                      <option value=\"North Korea\"> North Korea <\/option>\n                      <option value=\"South Korea\"> South Korea <\/option>\n                      <option value=\"Kosovo\"> Kosovo <\/option>\n                      <option value=\"Kuwait\"> Kuwait <\/option>\n                      <option value=\"Kyrgyzstan\"> Kyrgyzstan <\/option>\n                      <option value=\"Laos\"> Laos <\/option>\n                      <option value=\"Latvia\"> Latvia <\/option>\n                      <option value=\"Lebanon\"> Lebanon <\/option>\n                      <option value=\"Lesotho\"> Lesotho <\/option>\n                      <option value=\"Liberia\"> Liberia <\/option>\n                      <option value=\"Libya\"> Libya <\/option>\n                      <option value=\"Liechtenstein\"> Liechtenstein <\/option>\n                      <option value=\"Lithuania\"> Lithuania <\/option>\n                      <option value=\"Luxembourg\"> Luxembourg <\/option>\n                      <option value=\"Macau\"> Macau <\/option>\n                      <option value=\"Macedonia\"> Macedonia <\/option>\n                      <option value=\"Madagascar\"> Madagascar <\/option>\n                      <option value=\"Malawi\"> Malawi <\/option>\n                      <option value=\"Malaysia\"> Malaysia <\/option>\n                      <option value=\"Maldives\"> Maldives <\/option>\n                      <option value=\"Mali\"> Mali <\/option>\n                      <option value=\"Malta\"> Malta <\/option>\n                      <option value=\"Marshall Islands\"> Marshall Islands <\/option>\n                      <option value=\"Martinique\"> Martinique <\/option>\n                      <option value=\"Mauritania\"> Mauritania <\/option>\n                      <option value=\"Mauritius\"> Mauritius <\/option>\n                      <option value=\"Mayotte\"> Mayotte <\/option>\n                      <option value=\"Mexico\"> Mexico <\/option>\n                      <option value=\"Micronesia\"> Micronesia <\/option>\n                      <option value=\"Moldova\"> Moldova <\/option>\n                      <option value=\"Monaco\"> Monaco <\/option>\n                      <option value=\"Mongolia\"> Mongolia <\/option>\n                      <option value=\"Montenegro\"> Montenegro <\/option>\n                      <option value=\"Montserrat\"> Montserrat <\/option>\n                      <option value=\"Morocco\"> Morocco <\/option>\n                      <option value=\"Mozambique\"> Mozambique <\/option>\n                      <option value=\"Myanmar\"> Myanmar <\/option>\n                      <option value=\"Nagorno-Karabakh\"> Nagorno-Karabakh <\/option>\n                      <option value=\"Namibia\"> Namibia <\/option>\n                      <option value=\"Nauru\"> Nauru <\/option>\n                      <option value=\"Nepal\"> Nepal <\/option>\n                      <option value=\"Netherlands\"> Netherlands <\/option>\n                      <option value=\"Netherlands Antilles\"> Netherlands Antilles <\/option>\n                      <option value=\"New Caledonia\"> New Caledonia <\/option>\n                      <option value=\"New Zealand\"> New Zealand <\/option>\n                      <option value=\"Nicaragua\"> Nicaragua <\/option>\n                      <option value=\"Niger\"> Niger <\/option>\n                      <option value=\"Nigeria\"> Nigeria <\/option>\n                      <option value=\"Niue\"> Niue <\/option>\n                      <option value=\"Norfolk Island\"> Norfolk Island <\/option>\n                      <option value=\"Turkish Republic of Northern Cyprus\"> Turkish Republic of Northern Cyprus <\/option>\n                      <option value=\"Northern Mariana\"> Northern Mariana <\/option>\n                      <option value=\"Norway\"> Norway <\/option>\n                      <option value=\"Oman\"> Oman <\/option>\n                      <option value=\"Pakistan\"> Pakistan <\/option>\n                      <option value=\"Palau\"> Palau <\/option>\n                      <option value=\"Palestine\"> Palestine <\/option>\n                      <option value=\"Panama\"> Panama <\/option>\n                      <option value=\"Papua New Guinea\"> Papua New Guinea <\/option>\n                      <option value=\"Paraguay\"> Paraguay <\/option>\n                      <option value=\"Peru\"> Peru <\/option>\n                      <option value=\"Philippines\"> Philippines <\/option>\n                      <option value=\"Pitcairn Islands\"> Pitcairn Islands <\/option>\n                      <option value=\"Poland\"> Poland <\/option>\n                      <option value=\"Portugal\"> Portugal <\/option>\n                      <option value=\"Puerto Rico\"> Puerto Rico <\/option>\n                      <option value=\"Qatar\"> Qatar <\/option>\n                      <option value=\"Republic of the Congo\"> Republic of the Congo <\/option>\n                      <option value=\"Romania\"> Romania <\/option>\n                      <option value=\"Russia\"> Russia <\/option>\n                      <option value=\"Rwanda\"> Rwanda <\/option>\n                      <option value=\"Saint Barthelemy\"> Saint Barthelemy <\/option>\n                      <option value=\"Saint Helena\"> Saint Helena <\/option>\n                      <option value=\"Saint Kitts and Nevis\"> Saint Kitts and Nevis <\/option>\n                      <option value=\"Saint Lucia\"> Saint Lucia <\/option>\n                      <option value=\"Saint Martin\"> Saint Martin <\/option>\n                      <option value=\"Saint Pierre and Miquelon\"> Saint Pierre and Miquelon <\/option>\n                      <option value=\"Saint Vincent and the Grenadines\"> Saint Vincent and the Grenadines <\/option>\n                      <option value=\"Samoa\"> Samoa <\/option>\n                      <option value=\"San Marino\"> San Marino <\/option>\n                      <option value=\"Sao Tome and Principe\"> Sao Tome and Principe <\/option>\n                      <option value=\"Saudi Arabia\"> Saudi Arabia <\/option>\n                      <option value=\"Senegal\"> Senegal <\/option>\n                      <option value=\"Serbia\"> Serbia <\/option>\n                      <option value=\"Seychelles\"> Seychelles <\/option>\n                      <option value=\"Sierra Leone\"> Sierra Leone <\/option>\n                      <option value=\"Singapore\"> Singapore <\/option>\n                      <option value=\"Slovakia\"> Slovakia <\/option>\n                      <option value=\"Slovenia\"> Slovenia <\/option>\n                      <option value=\"Solomon Islands\"> Solomon Islands <\/option>\n                      <option value=\"Somalia\"> Somalia <\/option>\n                      <option value=\"Somaliland\"> Somaliland <\/option>\n                      <option value=\"South Africa\"> South Africa <\/option>\n                      <option value=\"South Ossetia\"> South Ossetia <\/option>\n                      <option value=\"South Sudan\"> South Sudan <\/option>\n                      <option value=\"Spain\"> Spain <\/option>\n                      <option value=\"Sri Lanka\"> Sri Lanka <\/option>\n                      <option value=\"Sudan\"> Sudan <\/option>\n                      <option value=\"Suriname\"> Suriname <\/option>\n                      <option value=\"Svalbard\"> Svalbard <\/option>\n                      <option value=\"eSwatini\"> eSwatini <\/option>\n                      <option value=\"Sweden\"> Sweden <\/option>\n                      <option value=\"Switzerland\"> Switzerland <\/option>\n                      <option value=\"Syria\"> Syria <\/option>\n                      <option value=\"Taiwan\"> Taiwan <\/option>\n                      <option value=\"Tajikistan\"> Tajikistan <\/option>\n                      <option value=\"Tanzania\"> Tanzania <\/option>\n                      <option value=\"Thailand\"> Thailand <\/option>\n                      <option value=\"Timor-Leste\"> Timor-Leste <\/option>\n                      <option value=\"Togo\"> Togo <\/option>\n                      <option value=\"Tokelau\"> Tokelau <\/option>\n                      <option value=\"Tonga\"> Tonga <\/option>\n                      <option value=\"Transnistria Pridnestrovie\"> Transnistria Pridnestrovie <\/option>\n                      <option value=\"Trinidad and Tobago\"> Trinidad and Tobago <\/option>\n                      <option value=\"Tristan da Cunha\"> Tristan da Cunha <\/option>\n                      <option value=\"Tunisia\"> Tunisia <\/option>\n                      <option value=\"Turkey\"> Turkey <\/option>\n                      <option value=\"Turkmenistan\"> Turkmenistan <\/option>\n                      <option value=\"Turks and Caicos Islands\"> Turks and Caicos Islands <\/option>\n                      <option value=\"Tuvalu\"> Tuvalu <\/option>\n                      <option value=\"Uganda\"> Uganda <\/option>\n                      <option value=\"Ukraine\"> Ukraine <\/option>\n                      <option value=\"United Arab Emirates\"> United Arab Emirates <\/option>\n                      <option value=\"United Kingdom\"> United Kingdom <\/option>\n                      <option value=\"Uruguay\"> Uruguay <\/option>\n                      <option value=\"Uzbekistan\"> Uzbekistan <\/option>\n                      <option value=\"Vanuatu\"> Vanuatu <\/option>\n                      <option value=\"Vatican City\"> Vatican City <\/option>\n                      <option value=\"Venezuela\"> Venezuela <\/option>\n                      <option value=\"Vietnam\"> Vietnam <\/option>\n                      <option value=\"British Virgin Islands\"> British Virgin Islands <\/option>\n                      <option value=\"Isle of Man\"> Isle of Man <\/option>\n                      <option value=\"US Virgin Islands\"> US Virgin Islands <\/option>\n                      <option value=\"Wallis and Futuna\"> Wallis and Futuna <\/option>\n                      <option value=\"Western Sahara\"> Western Sahara <\/option>\n                      <option value=\"Yemen\"> Yemen <\/option>\n                      <option value=\"Zambia\"> Zambia <\/option>\n                      <option value=\"Zimbabwe\"> Zimbabwe <\/option>\n                      <option value=\"other\"> Other <\/option>\n                    <\/select>\n                    <label class=\"form-sub-label\" for=\"input_155_country\" id=\"sublabel_155_country\" style=\"min-height:13px\"> Country <\/label>\n                  <\/span>\n                <\/td>\n              <\/tr>\n            <\/tbody>\n          <\/table>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_157\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_157\" for=\"input_157\"> Surname at birth <\/label>\n        <div id=\"cid_157\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_157\" name=\"q157_surnameAt\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_157\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_37\">\n        <label class=\"form-label form-label-top\" id=\"label_37\" for=\"input_37\">\n          Gender\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_37\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_37\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_37_0\" name=\"q37_gender\" value=\"Male\" required=\"\" \/>\n              <label id=\"label_input_37_0\" for=\"input_37_0\"> Male <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_37_1\" name=\"q37_gender\" value=\"Female\" required=\"\" \/>\n              <label id=\"label_input_37_1\" for=\"input_37_1\"> Female <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_datetime\" id=\"id_38\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_38\" for=\"lite_mode_38\">\n          Date of birth\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_38\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <div style=\"display:none\">\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"month_38\" name=\"q38_dateOf[month]\" size=\"2\" data-maxlength=\"2\" value=\"\" required=\"\" aria-labelledby=\"label_38 sublabel_38_month\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"month_38\" id=\"sublabel_38_month\" style=\"min-height:13px\"> Month <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"day_38\" name=\"q38_dateOf[day]\" size=\"2\" data-maxlength=\"2\" value=\"\" required=\"\" aria-labelledby=\"label_38 sublabel_38_day\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"day_38\" id=\"sublabel_38_day\" style=\"min-height:13px\"> Day <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[required, limitDate]\" id=\"year_38\" name=\"q38_dateOf[year]\" size=\"4\" data-maxlength=\"4\" value=\"\" required=\"\" aria-labelledby=\"label_38 sublabel_38_year\" \/>\n                <label class=\"form-sub-label\" for=\"year_38\" id=\"sublabel_38_year\" style=\"min-height:13px\"> Year <\/label>\n              <\/span>\n            <\/div>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" class=\"form-textbox validate[required, limitDate, validateLiteDate]\" id=\"lite_mode_38\" size=\"12\" data-maxlength=\"12\" data-age=\"\" value=\"\" required=\"\" data-format=\"mmddyyyy\" data-seperator=\"-\" placeholder=\"mm-dd-yyyy\" aria-labelledby=\"label_38 sublabel_38_litemode\" \/>\n              <img alt=\"Pick a Date\" id=\"input_38_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" style=\"vertical-align:middle;margin-left:5px\" data-component=\"datetime\" aria-hidden=\"true\" \/>\n              <label class=\"form-sub-label\" for=\"lite_mode_38\" id=\"sublabel_38_litemode\" style=\"min-height:13px\"> Date <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <label class=\"form-sub-label\" for=\"input_38_pick\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\"> Date Picker Icon <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_158\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_158\" for=\"input_158\">\n          Age\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_158\" class=\"form-input-wide jf-required\">\n          <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_158\" name=\"q158_age\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_158 sublabel_input_158\" required=\"\" \/>\n            <label class=\"form-sub-label\" for=\"input_158\" id=\"sublabel_input_158\" style=\"min-height:13px\"> Please enter a number between 1-120 <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_39\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_39\" for=\"input_39\">\n          Town of birth\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_39\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_39\" name=\"q39_townOf\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_39\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_159\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_159\" for=\"input_159\">\n          Country of birth\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_159\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_159\" name=\"q159_countryOf\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_159\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_160\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_160\" for=\"input_160\">\n          Ethnic groups\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_160\" class=\"form-input-wide jf-required\">\n          <div class=\"form-multiple-column\" data-columncount=\"3\" role=\"group\" aria-labelledby=\"label_160\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_160_0\" name=\"q160_ethnicGroups[]\" value=\"European\" required=\"\" \/>\n              <label id=\"label_input_160_0\" for=\"input_160_0\"> European <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_160_1\" name=\"q160_ethnicGroups[]\" value=\"M\u0101ori\" required=\"\" \/>\n              <label id=\"label_input_160_1\" for=\"input_160_1\"> M\u0101ori <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_160_2\" name=\"q160_ethnicGroups[]\" value=\"NZ M\u0101ori Descent\" required=\"\" \/>\n              <label id=\"label_input_160_2\" for=\"input_160_2\"> NZ M\u0101ori Descent <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_160_3\" name=\"q160_ethnicGroups[]\" value=\"Samoan\" required=\"\" \/>\n              <label id=\"label_input_160_3\" for=\"input_160_3\"> Samoan <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_160_4\" name=\"q160_ethnicGroups[]\" value=\"Tongan\" required=\"\" \/>\n              <label id=\"label_input_160_4\" for=\"input_160_4\"> Tongan <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_160_5\" name=\"q160_ethnicGroups[]\" value=\"Cook Island M\u0101ori\" required=\"\" \/>\n              <label id=\"label_input_160_5\" for=\"input_160_5\"> Cook Island M\u0101ori <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_160_6\" name=\"q160_ethnicGroups[]\" value=\"Chinese\" required=\"\" \/>\n              <label id=\"label_input_160_6\" for=\"input_160_6\"> Chinese <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_160_7\" name=\"q160_ethnicGroups[]\" value=\"Indian\" required=\"\" \/>\n              <label id=\"label_input_160_7\" for=\"input_160_7\"> Indian <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_160_8\" name=\"q160_ethnicGroups[]\" value=\"Other\" required=\"\" \/>\n              <label id=\"label_input_160_8\" for=\"input_160_8\"> Other <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_161\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_161\" for=\"input_161\">\n          Place of death\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_161\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_161\" name=\"q161_placeOf\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_161\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_42\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_42\" for=\"input_42\">\n          Usual Occupation or Profession (before retirement)\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_42\" class=\"form-input-wide jf-required\">\n          <input type=\"text\" id=\"input_42\" name=\"q42_usualOccupation42\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_42\" required=\"\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_162\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_162\" for=\"input_162\">\n          Did they have any children?\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_162\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_162\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_162_0\" name=\"q162_didThey\" value=\"Yes\" required=\"\" \/>\n              <label id=\"label_input_162_0\" for=\"input_162_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_162_1\" name=\"q162_didThey\" value=\"No\" required=\"\" \/>\n              <label id=\"label_input_162_1\" for=\"input_162_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_58\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_58\" class=\"form-header\" data-component=\"header\">\n              Latest Relationship\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_dropdown\" id=\"id_169\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_169\" for=\"input_169\"> Relationship status at time of death <\/label>\n        <div id=\"cid_169\" class=\"form-input-wide\">\n          <select class=\"form-dropdown\" id=\"input_169\" name=\"q169_relationshipStatus169\" style=\"width:150px\" data-component=\"dropdown\" aria-labelledby=\"label_169\">\n            <option value=\"\">  <\/option>\n            <option value=\"Married\"> Married <\/option>\n            <option value=\"Civil Union\"> Civil Union <\/option>\n            <option value=\"De Facto Relationship\"> De Facto Relationship <\/option>\n            <option value=\"Spouse (partner deceased)\"> Spouse (partner deceased) <\/option>\n            <option value=\"Separated (from marriage or civil union)\"> Separated (from marriage or civil union) <\/option>\n            <option value=\"Marriage disolved\/divorced\"> Marriage disolved\/divorced <\/option>\n            <option value=\"Never in a legal relationship\"> Never in a legal relationship <\/option>\n          <\/select>\n        <\/div>\n      <\/li>\n      <li id=\"cid_60\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_60\" class=\"form-header\" data-component=\"header\">\n            <\/h2>\n            <div id=\"subHeader_60\" class=\"form-subHeader\">\n              Details of most recent relationship:\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fullname\" id=\"id_62\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_62\" for=\"first_62\"> Spouse\/Partners Full Name <\/label>\n        <div id=\"cid_62\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_62\" name=\"q62_spousepartnersFull[first]\" class=\"form-textbox\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_62 sublabel_62_first\" \/>\n              <label class=\"form-sub-label\" for=\"first_62\" id=\"sublabel_62_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_62\" name=\"q62_spousepartnersFull[last]\" class=\"form-textbox\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_62 sublabel_62_last\" \/>\n              <label class=\"form-sub-label\" for=\"last_62\" id=\"sublabel_62_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_63\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_63\" for=\"input_63\"> Spouse\/Partner maiden name (if applicable) <\/label>\n        <div id=\"cid_63\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_63\" name=\"q63_spousepartnerMaiden\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_63\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_64\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_64\" for=\"input_64\"> Spouse\/Partner date of birth <\/label>\n        <div id=\"cid_64\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_64\" name=\"q64_spousepartnerDate\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_64\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_66\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_66\" for=\"input_66\"> Place of marriage\/civil union <\/label>\n        <div id=\"cid_66\" class=\"form-input-wide\">\n          <input type=\"text\" id=\"input_66\" name=\"q66_placeOf66\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_66\" \/>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_datetime\" id=\"id_143\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_143\" for=\"lite_mode_143\"> Date of marriage\/civil union <\/label>\n        <div id=\"cid_143\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <div style=\"display:none\">\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"month_143\" name=\"q143_dateOf143[month]\" size=\"2\" data-maxlength=\"2\" value=\"\" aria-labelledby=\"label_143 sublabel_143_month\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"month_143\" id=\"sublabel_143_month\" style=\"min-height:13px\"> Month <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"day_143\" name=\"q143_dateOf143[day]\" size=\"2\" data-maxlength=\"2\" value=\"\" aria-labelledby=\"label_143 sublabel_143_day\" \/>\n                <span class=\"date-separate\" aria-hidden=\"true\">\n                  \u00a0-\n                <\/span>\n                <label class=\"form-sub-label\" for=\"day_143\" id=\"sublabel_143_day\" style=\"min-height:13px\"> Day <\/label>\n              <\/span>\n              <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n                <input type=\"tel\" class=\"form-textbox validate[limitDate]\" id=\"year_143\" name=\"q143_dateOf143[year]\" size=\"4\" data-maxlength=\"4\" value=\"\" aria-labelledby=\"label_143 sublabel_143_year\" \/>\n                <label class=\"form-sub-label\" for=\"year_143\" id=\"sublabel_143_year\" style=\"min-height:13px\"> Year <\/label>\n              <\/span>\n            <\/div>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" class=\"form-textbox validate[limitDate, validateLiteDate]\" id=\"lite_mode_143\" size=\"12\" data-maxlength=\"12\" data-age=\"\" value=\"\" data-format=\"mmddyyyy\" data-seperator=\"-\" placeholder=\"mm-dd-yyyy\" aria-labelledby=\"label_143 sublabel_143_litemode\" \/>\n              <img alt=\"Pick a Date\" id=\"input_143_pick\" src=\"https:\/\/cdn.jotfor.ms\/images\/calendar.png\" style=\"vertical-align:middle;margin-left:5px\" data-component=\"datetime\" aria-hidden=\"true\" \/>\n              <label class=\"form-sub-label\" for=\"lite_mode_143\" id=\"sublabel_143_litemode\" style=\"min-height:13px\"> Date <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <label class=\"form-sub-label\" for=\"input_143_pick\" style=\"border:0;clip:rect(0 0 0 0);height:1px;margin:-1px;overflow:hidden;padding:0;position:absolute;width:1px;white-space:nowrap\"> Date Picker Icon <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_65\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_65\" for=\"input_65\"> Age at time of marriage\/civil union <\/label>\n        <div id=\"cid_65\" class=\"form-input-wide\">\n          <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_65\" name=\"q65_ageAt\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_65 sublabel_input_65\" \/>\n            <label class=\"form-sub-label\" for=\"input_65\" id=\"sublabel_input_65\" style=\"min-height:13px\"> Please enter a number between 0-120 <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_163\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_163\" for=\"input_163\"> Spouse\/Partners age, if living <\/label>\n        <div id=\"cid_163\" class=\"form-input-wide\">\n          <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n            <input type=\"text\" id=\"input_163\" name=\"q163_spousepartnersAge\" data-type=\"input-textbox\" class=\"form-textbox\" size=\"20\" value=\"\" data-component=\"textbox\" aria-labelledby=\"label_163 sublabel_input_163\" \/>\n            <label class=\"form-sub-label\" for=\"input_163\" id=\"sublabel_input_163\" style=\"min-height:13px\"> Please enter a number between 0-120 <\/label>\n          <\/span>\n        <\/div>\n      <\/li>\n      <li id=\"cid_67\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_67\" class=\"form-header\" data-component=\"header\">\n            <\/h2>\n            <div id=\"subHeader_67\" class=\"form-subHeader\">\n              Previous relationship\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_radio\" id=\"id_164\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_164\" for=\"input_164\"> Was there another major prior relationship? <\/label>\n        <div id=\"cid_164\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_164\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_164_0\" name=\"q164_wasThere\" value=\"Yes\" \/>\n              <label id=\"label_input_164_0\" for=\"input_164_0\"> Yes <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio\" id=\"input_164_1\" name=\"q164_wasThere\" value=\"No\" \/>\n              <label id=\"label_input_164_1\" for=\"input_164_1\"> No <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_53\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group \">\n          <div class=\"header-text httal htvam\">\n            <h2 id=\"header_53\" class=\"form-header\" data-component=\"header\">\n              Parents&#x27; details\n            <\/h2>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_54\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_54\" for=\"first_54\">\n          Mother's full name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_54\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_54\" name=\"q54_mothersFull[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_54 sublabel_54_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_54\" id=\"sublabel_54_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_54\" name=\"q54_mothersFull[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_54 sublabel_54_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_54\" id=\"sublabel_54_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fullname\" id=\"id_170\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_170\" for=\"first_170\"> Mother's name at birth, if different <\/label>\n        <div id=\"cid_170\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_170\" name=\"q170_mothersName[first]\" class=\"form-textbox\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_170 sublabel_170_first\" \/>\n              <label class=\"form-sub-label\" for=\"first_170\" id=\"sublabel_170_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_170\" name=\"q170_mothersName[last]\" class=\"form-textbox\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_170 sublabel_170_last\" \/>\n              <label class=\"form-sub-label\" for=\"last_170\" id=\"sublabel_170_last\" style=\"min-height:13px\"> Maiden Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_55\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_55\" for=\"first_55\">\n          Father's full name\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_55\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_55\" name=\"q55_fathersFull[first]\" class=\"form-textbox validate[required]\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_55 sublabel_55_first\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"first_55\" id=\"sublabel_55_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_55\" name=\"q55_fathersFull[last]\" class=\"form-textbox validate[required]\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_55 sublabel_55_last\" required=\"\" \/>\n              <label class=\"form-sub-label\" for=\"last_55\" id=\"sublabel_55_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_fullname\" id=\"id_171\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_171\" for=\"first_171\"> Father's name at birth, if different <\/label>\n        <div id=\"cid_171\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"first_171\" name=\"q171_mothersName171[first]\" class=\"form-textbox\" size=\"10\" value=\"\" data-component=\"first\" aria-labelledby=\"label_171 sublabel_171_first\" \/>\n              <label class=\"form-sub-label\" for=\"first_171\" id=\"sublabel_171_first\" style=\"min-height:13px\"> First Name <\/label>\n            <\/span>\n            <span class=\"form-sub-label-container \" style=\"vertical-align:top\">\n              <input type=\"text\" id=\"last_171\" name=\"q171_mothersName171[last]\" class=\"form-textbox\" size=\"15\" value=\"\" data-component=\"last\" aria-labelledby=\"label_171 sublabel_171_last\" \/>\n              <label class=\"form-sub-label\" for=\"last_171\" id=\"sublabel_171_last\" style=\"min-height:13px\"> Last Name <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_radio\" id=\"id_165\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_165\" for=\"input_165\">\n          The total cost of this service including G.S.T. is $1750. Payment Options available are:\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_165\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_165\" data-component=\"radio\">\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_165_0\" name=\"q165_theTotal165\" value=\"Bank Deposit to: BNZ Tauranga 02-0432-0046926-00\" required=\"\" \/>\n              <label id=\"label_input_165_0\" for=\"input_165_0\"> Bank Deposit to: BNZ Tauranga 02-0432-0046926-00 <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_165_1\" name=\"q165_theTotal165\" value=\"Credit Card over the phone (07 543 1977)\" required=\"\" \/>\n              <label id=\"label_input_165_1\" for=\"input_165_1\"> Credit Card over the phone (07 543 1977) <\/label>\n            <\/span>\n            <span class=\"form-radio-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"radio\" class=\"form-radio validate[required]\" id=\"input_165_2\" name=\"q165_theTotal165\" value=\"or Cash\" required=\"\" \/>\n              <label id=\"label_input_165_2\" for=\"input_165_2\"> or Cash <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_166\">\n        <div id=\"cid_166\" class=\"form-input-wide\">\n          <div id=\"text_166\" class=\"form-html\" data-component=\"text\">\n            <p>Our terms of trade are payment in full at the time of the removal. We can be contacted on 07 543 1977 at anytime.<\/p>\n            <p> <\/p>\n            <p>Essential Care*<br \/>Price: $ 1,750.00<\/p>\n            <p>Total<br \/>$ 1,750.00<\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_checkbox\" id=\"id_167\">\n        <label class=\"form-label form-label-top form-label-auto\" id=\"label_167\" for=\"input_167\">\n          Terms and Conditions (please select all)\n          <span class=\"form-required\">\n            *\n          <\/span>\n        <\/label>\n        <div id=\"cid_167\" class=\"form-input-wide jf-required\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_167\" data-component=\"checkbox\">\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_167_0\" name=\"q167_termsAnd[]\" value=\"I give Todd Gower Signature Funerals authority to manage funeral proceedings\" required=\"\" \/>\n              <label id=\"label_input_167_0\" for=\"input_167_0\"> I give Todd Gower Signature Funerals authority to manage funeral proceedings <\/label>\n            <\/span>\n            <span class=\"form-checkbox-item\" style=\"clear:left\">\n              <span class=\"dragger-item\">\n              <\/span>\n              <input type=\"checkbox\" class=\"form-checkbox validate[required]\" id=\"input_167_1\" name=\"q167_termsAnd[]\" value=\"By submitting this payment I give authorisation for the collection of the deceased. I understand that I will be required to sign paperwork to this effect.\" required=\"\" \/>\n              <label id=\"label_input_167_1\" for=\"input_167_1\"> By submitting this payment I give authorisation for the collection of the deceased. I understand that I will be required to sign paperwork to this effect. <\/label>\n            <\/span>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_168\">\n        <div id=\"cid_168\" class=\"form-input-wide\">\n          <div id=\"text_168\" class=\"form-html\" data-component=\"text\">\n            <p><strong>After you submit the above form please contact us on (07) 543 1977 to confirm that we have received your information and we will talk your through the rest of the process.<\/strong><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_widget\" id=\"id_172\">\n        <div id=\"cid_172\" class=\"\">\n          <div style=\"width:100%;text-align:Left\" data-component=\"widget-directEmbed\">\n            <div class=\"direct-embed-widgets google-analytics-widget \" data-type=\"direct-embed\" style=\"width:50px;min-height:50px\">\n              <div class=\"google_analytics_widget\">\n                <script>\n                var analyticsFormId = '{analyticsFormId}';\nvar analyticsAutoLink = '';\n(function(i, s, o, g, r, a, m)\n{\n  i['GoogleAnalyticsObject'] = r;\n  i[r] = i[r] ||\n  function()\n  {\n    (i[r].q = i[r].q || []).push(arguments)\n  }, i[r].l = 1 * new Date();\n  a = s.createElement(o), m = s.getElementsByTagName(o)[0];\n  a.async = 1;\n  a.src = g;\n  m.parentNode.insertBefore(a, m)\n})(window, document, 'script', '\/\/www.google-analytics.com\/analytics.js', 'ga');\n\nga('create', 'UA-84927146-1', 'auto', {\n  'allowLinker': true\n});\nga('send', 'pageview');\nif (window.analyticsAutoLink && analyticsAutoLink != '<empty>')\n{\n  analyticsAutoLink = analyticsAutoLink.replace(\/ \/g, '').split(\/[,\\n]\/g);\n  ga('require', 'linker');\n  ga('linker:autoLink', analyticsAutoLink);\n}\n                <\/script>\n                <script src=\"\/\/widgets.jotform.io\/googleanalytics\/scripts.js\" type=\"text\/javascript\"><\/script>\n              <\/div>\n            <\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_61\">\n        <div id=\"cid_61\" class=\"form-input-wide\">\n          <div style=\"margin-left:156px\" class=\"form-buttons-wrapper \">\n            <button id=\"input_61\" type=\"submit\" class=\"form-submit-button\" data-component=\"button\">\n              Submit\n            <\/button>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li style=\"display:none\">\n        Should be Empty:\n        <input type=\"text\" name=\"website\" value=\"\" \/>\n      <\/li>\n    <\/ul>\n  <\/div>\n  <script>\n  JotForm.showJotFormPowered = \"old_footer\";\n  <\/script>\n  <input type=\"hidden\" id=\"simple_spc\" name=\"simple_spc\" value=\"92196291992874\" \/>\n  <script type=\"text\/javascript\">\n  document.getElementById(\"si\" + \"mple\" + \"_spc\").value = \"92196291992874-92196291992874\";\n  <\/script>\n  <script src=\"https:\/\/cdn.jotfor.ms\/js\/widgetResizer.js?REV=3.3.13909\" type=\"text\/javascript\"><\/script>\n<\/form><\/body>\n<\/html>\n","TGFS Essential Care application form",Array);(function(){window.handleIFrameMessage=function(e){if(!e.data||!e.data.split)return;var args=e.data.split(":");if(args[2]!="92196291992874"){return;}
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