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.
First Name *
Middle Name
Last Name *
First Name at Birth (if different to above)
Last Name at Birth (if different to above) i.e. maiden name if applicable
Phone Number *
Email Address
Usual Physical Address
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
Contact Person's Address, Phone Number and Email
Date of Birth
Place of Birth
If you were not born in NZ, please state when you arrived in NZ
Ethnic Group
Are you descended from a NZ Maori?
Gender
Main Occupation (Before retirement)
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
Sons - Please enter first name and date of birth of each son
PARENTS
Mother's full name (including surname) the day you were born
Mothers Maiden name (if applicable)
Mother's Main Occupation - Before Retirement
Father's Full Name
Father's Occupation - Before Retirement
RELATIONSHIP STATUS
Current Relationship Status
Clear selection
Age at Marriage
Place of Marriage
Date of Birth of Spouse/Partner (If living)
Gender
Clear selection
Spouse/Partner Full Name before this marriage
PREVIOUS RELATIONSHIPS IF APPLICABLE
Clear selection
Age at Marriage
Place of Marriage
Date of Birth of Spouse/Partner (if living)
Gender
Clear selection
Spouse/Partner Full Name before this marriage
Any other previous relationships
FUNERAL WISHES
I would like a...
Clear selection
If cremated, I would like my ashes to be...
If the ashes are to be buried and a plot is already organised, please state details here
Funeral Service
Clear selection
I would like the service to be held at...
I would like the service to be taken by...
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)
Clear selection
The style of hearse I would like is... (Prices vary)
Clear selection
I would like the casket to be...
I would like flowers on the casket
Clear selection
Colours/Types of flowers
Petals to be placed on the casket?
Clear selection
Flower spray to be retrieved?
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.
I would like...
If you clicked yes for service sheets, bookmarks, catering...How many?
I would like a newspaper notice to be placed in the...
Newspaper Notice details...
I would like a newspaper header (there are set options available which can be discussed with a team member)
This is the music I would like at the service
I would like a donation box at the service
Clear selection
If yes, I would like the donations to go to
I would like a viewing
Clear selection
If yes, I would like it to be held at...
Clear selection
Do any of these apply to you?
If yes, details...
CONTACTS
My will is held by (name, address, phone)
The executor of my will is (name, address, phone)
My next of kin is... Please provide their name, phone number and relationship to you
My Doctor is...
The Funeral Director I have been speaking with is...
Clear selection
Any other details...
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