Assistance available
24 Hours 7 Days

(03) 5470 5951

leidle@mafunerals.com.au

12 Campbell Street, Castlemaine

195 High Street, Kangaroo Flat (Bendigo)

Online Pre-Arranged Funeral Service

 

This form has been prepared in two sections, Section A covers Personal Details, and Section B covers your Funeral Requests.

 

Section A: My Personal Details

Title *

Given Names *

Surname *

Address *

Phone Number *

Email Address *

Place of Birth *

Date of Birth *

 

 

Occupation (If retired former occupation) *

Marital Status *
 Married Widowed Divorced Never Married

Name of Spouse (including maiden name)

Place of Marriage

Date of Marriage

Previous marriage (if any) Widowed Divorced Separated

Name of Spouse (including maiden name)

Place of Marriage

Date of Marriage

Childrens' Details

1st Child

 Male Female

Name

Date of Birth

2nd Child

 Male Female

Name

Date of Birth

3rd Child

 Male Female

Name

Date of Birth

4th Child

 Male Female

Name

Date of Birth

5th Child

 Male Female

Name

Date of Birth

6th Child

 Male Female

Name

Date of Birth

Your Parents Details

Father's full name

Father’s occupation

Mother’s full name

Mother’s maiden name

Mother’s occupation

Next of Kin Details

Next of Kin *

Full Name of Next of Kin

Phone

Address

Executor

Full Name of Executor

Phone

Address

Doctor

Full name of Doctor

Phone

Address

Section B: Your Funeral Preferences

I would like *
 a burial service (Please nominate cemetery and grave number if pre-purchased) a cremation service (please nominate crematorium)

 

Wishes for ashes  Urn Placement Crematorium site Scattering

 

I would like my service at *
 my church a funeral chapel another location with a full funeral procession to cemetery / crematorium without a funeral procession

 

I would like the service conducted by *
 a minister of religion a civil celebrant another person

 

My coffin / casket choice is

 

In regards to a viewing *
 I would like to have an open coffin for Family only I do not want an open coffin or viewing

 

The songs I would like played at my services are

 pre-recorded Live e.g. Bagpiper…, Organist, Musician, Bugler (Last Post, Reveille, etc)

 

I would like a flag draped over my coffin
 Australian RAAF Navy (White Ensign) Union Jack Other

 

In regards to flowers at the service…

I would like the following varieties

I would prefer people did not send flowers and request they instead make a donation to the charity shown below.

 

I would like to be dressed in *
 a favourite outfit club outfit/uniform night wear other

 

I would like my death / funeral notices to appear in the following newspapers.

 

In regard to immediate family support I would like
 cars to be provided them to use their own vehicles

 

I would like to have pallbearers at the service

 

Specific items I would like at the service
 Medals Trophies Music instruments Favourite photos Sporting item Others

I would like a special DVD presentation of my life shown at the service
 Yes No

 

I would like a Standard Order of service produced for hand-out at the service
 Yes No

 

I would like a Memorial Book supplied as a family keepsake
 Yes No

 

My Wake / After-Service Celebrations

 

I would prefer my family and friends celebrate my life with *
 a catered gathering at the chapel a function at a family member's home a catered function at a club or similar I would prefer there was no after-service activity others

 

Other Requests

 

As a member of the following Clubs/Associations I would specially like them notified of my service

 

Important

 

 

Would you like to discuss a pre-paid funeral with us?  Yes No TICK here and a representative will contact you personally within 2 working days.