Personal Details and Funeral Wishes
The questions in this form refer to the loved one whose funeral wishes are being planned.
If you are filling this form in on behalf of someone else, please enter the answers from their perspective i.e. their address and contact details. You will have the opportunity to put your contact details in the contact person box.
It can take a few minutes to fill, so make sure you have a cup of tea handy, and a few personal documents, such as birth certificates and marriage certificates. To register for a Death Certificate when somebody passes, Births, Deaths and Marriages require the answers to every one of the questions before the 'Funeral Wishes' section. If you are unsure, or do not want to answer a particular question please put TBA (to be advised) and we can discuss the answer in person if you prefer.
* Required
First Name
*
Your answer
Middle Name
Your answer
Last Name
*
Your answer
First Name at Birth (if different to above)
Your answer
Last Name at Birth (if different to above) i.e. maiden name if applicable
Your answer
Phone Number
*
Your answer
Email Address
Your answer
Usual Physical Address
Your answer
Contact Person's Full Name and Relationship to you - This is the person we will liaise with and who will be responsible for your interests
Your answer
Contact Person's Address, Phone Number and Email
Your answer
Date of Birth
Your answer
Place of Birth
Your answer
If you were not born in NZ, please state when you arrived in NZ
Your answer
Ethnic Group
NZ European
Maori
Indian
Samoan
Chinese
Other:
Are you descended from a NZ Maori?
Yes
No
Gender
Male
Female
Other:
Main Occupation (Before retirement)
Your answer
CHILDREN
Including legally adopted children (do not include children who have been adopted out)
If any children have passed away, please enter their date of birth and age at death
Daughters - Please enter first name and date of birth of each daughter
Your answer
Sons - Please enter first name and date of birth of each son
Your answer
PARENTS
Mother's full name (including surname) the day you were born
Your answer
Mothers Maiden name (if applicable)
Your answer
Mother's Main Occupation - Before Retirement
Your answer
Father's Full Name
Your answer
Father's Occupation - Before Retirement
Your answer
RELATIONSHIP STATUS
Current Relationship Status
Married
In a de facto relationship
Permanently Separated
Spouse/partner deceased
In a Civil Union
Marriage/Civil Union Dissolved
Separated from a de facto partner
Never in a legal relationship
Clear selection
Age at Marriage
Your answer
Place of Marriage
Your answer
Date of Birth of Spouse/Partner (If living)
Your answer
Gender
Male
Female
Prefer not to say
Other:
Clear selection
Spouse/Partner Full Name before this marriage
Your answer
PREVIOUS RELATIONSHIPS IF APPLICABLE
Marriage
Civil Union
de facto
None
Clear selection
Age at Marriage
Your answer
Place of Marriage
Your answer
Date of Birth of Spouse/Partner (if living)
Your answer
Gender
Female
Male
Prefer not to say
Other:
Clear selection
Spouse/Partner Full Name before this marriage
Your answer
Any other previous relationships
Your answer
FUNERAL WISHES
I would like a...
Cremation
Burial
I wish to discuss this later
Clear selection
If cremated, I would like my ashes to be...
Held by Family
Held by Hopes
Scattered by Family
Scattered by Hopes
Buried by Family
Buried by Cemetery Staff
Other
If the ashes are to be buried and a plot is already organised, please state details here
Your answer
Funeral Service
Yes
No
I wish to discuss this later
Clear selection
I would like the service to be held at...
Your answer
I would like the service to be taken by...
Your answer
The style of coffin I would like is... (Please note prices vary and some caskets are available for hire. Please speak with a team member for more information)
Cardboard Casket (Direct Cremation Only) If being used as a liner inside a hire casket, a traditional casket also needs to be chosen as the outer
Rimu Veneer Grosvenor (Other colours available)
White Richmond (Other colours available)
Mahogany Veneer Status (other colours available)
Serenity Driftwood
Recycled Timber
Carved Casket
Woven Willow
Mount Scene (Other prints available)
Other:
Clear selection
The style of hearse I would like is... (Prices vary)
White Jaguar
Black Jaguar
Indian Motorbike Hearse
Other:
Clear selection
I would like the casket to be...
Carried in by pallbearers
Carried out by pallbearers
In place
Lowered
I would like flowers on the casket
Yes
No
Other:
Clear selection
Colours/Types of flowers
Your answer
Petals to be placed on the casket?
Yes
No
Clear selection
Flower spray to be retrieved?
Yes
No
Unsure
Clear selection
These are my wishes in regards to my jewellery - e.g. some prefer their jewellery to be removed, others prefer it to be buried/cremated with them.
Your answer
I would like...
Service Sheets
Memorial Book
Framed photo
Photo Board
Photo Slideshow
Video recording of the service
Live Streaming
Catering/Refreshments
Other:
If you clicked yes for service sheets, bookmarks, catering...How many?
Your answer
I would like a newspaper notice to be placed in the...
Bay of Plenty Times
New Zealand Herald
Sunlive
Other:
Newspaper Notice details...
Your answer
I would like a newspaper header (there are set options available which can be discussed with a team member)
Your answer
This is the music I would like at the service
Your answer
I would like a donation box at the service
Yes
No
Unsure
Clear selection
If yes, I would like the donations to go to
Your answer
I would like a viewing
Yes
No
Unsure
Clear selection
If yes, I would like it to be held at...
Funeral home
Family home
Marae
Other:
Clear selection
Do any of these apply to you?
RSA Participation
Any Non Military Honour/Award
I am a JP or Marriage Celebrant
If yes, details...
Your answer
CONTACTS
My will is held by (name, address, phone)
Your answer
The executor of my will is (name, address, phone)
Your answer
My next of kin is... Please provide their name, phone number and relationship to you
Your answer
My Doctor is...
Your answer
The Funeral Director I have been speaking with is...
Tony Hope
Ricky Hope
Kathy Sleep
Richard Hope
Oliver Marriner
No one yet
Other:
Clear selection
Any other details...
Your answer
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