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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 *
MarriedWidowedDivorcedNever Married

Name of Spouse (including maiden name)

Place of Marriage

Date of Marriage

Previous marriage (if any)WidowedDivorcedSeparated

Name of Spouse (including maiden name)

Place of Marriage

Date of Marriage

Childrens' Details

1st Child

MaleFemale

Name

Date of Birth

2nd Child

MaleFemale

Name

Date of Birth

3rd Child

MaleFemale

Name

Date of Birth

4th Child

MaleFemale

Name

Date of Birth

5th Child

MaleFemale

Name

Date of Birth

6th Child

MaleFemale

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 UrnPlacementCrematorium siteScattering

 

I would like my service at *
my churcha funeral chapelanother locationwith a full funeral procession to cemetery / crematoriumwithout a funeral procession

 

I would like the service conducted by *
a minister of religiona civil celebrantanother person

 

My coffin / casket choice is

 

In regards to a viewing *
I would like to have an open coffin forFamily onlyI do not want an open coffin or viewing

 

The songs I would like played at my services are

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

 

I would like a flag draped over my coffin
AustralianRAAFNavy (White Ensign)Union JackOther

 

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 outfitclub outfit/uniformnight wearother

 

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 providedthem to use their own vehicles

 

I would like to have pallbearers at the service

 

Specific items I would like at the service
MedalsTrophiesMusic instrumentsFavourite photosSporting itemOthers

I would like a special DVD presentation of my life shown at the service
YesNo

 

I would like a Standard Order of service produced for hand-out at the service
YesNo

 

I would like a Memorial Book supplied as a family keepsake
YesNo

 

My Wake / After-Service Celebrations

 

I would prefer my family and friends celebrate my life with *
a catered gathering at the chapela function at a family member's homea catered function at a club or similarI would prefer there was no after-service activityothers

 

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? YesNo TICK here and a representative will contact you personally within 2 working days.