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.
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
Are you descended from a NZ Maori?
Gender
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
Age at Marriage
Your answer
Place of Marriage
Your answer
Date of Birth of Spouse/Partner (If living)
Your answer
Gender
Spouse/Partner Full Name before this marriage
Your answer
PREVIOUS RELATIONSHIPS IF APPLICABLE
Age at Marriage
Your answer
Place of Marriage
Your answer
Date of Birth of Spouse/Partner (if living)
Your answer
Gender
Spouse/Partner Full Name before this marriage
Your answer
Any other previous relationships
Your answer
FUNERAL WISHES
I would like a...
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
Your answer
Funeral Service
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)
The style of hearse I would like is... (Prices vary)
I would like the casket to be...
I would like flowers on the casket
Colours/Types of flowers
Your answer
Petals to be placed on the casket?
Flower spray to be retrieved?
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...
If you clicked yes for service sheets, bookmarks, catering...How many?
Your answer
I would like a newspaper notice to be placed in the...
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
If yes, I would like the donations to go to
Your answer
I would like a viewing
If yes, I would like it to be held at...
Do any of these apply to you?
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...
Any other details...
Your answer
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