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 their contact details.
You can 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. You do not need to fill in every space, so feel free to leave anything out if you are not sure, or do not want to answer a particular question.
* 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)
Your answer
Phone Number
*
Your answer
Email Address
Your answer
Usual Physical Address
Your answer
Contact Person - Who would you like us to contact if you are unavailable (Name, Phone, Address, 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
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 (Maiden in brackets)
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
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:
Spouse/Partner Full Name (Prior to this marriage)
Your answer
PREVIOUS RELATIONSHIP
Marriage
Civil Union
de facto
None
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:
Spouse/Partner Full Name
Your answer
Any other previous relationships
Your answer
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