Title *
MrMrsDrMissMs

Given Names *

Surname *

Address *

Phone Number *

Email Address *

Place 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

MaleFemale

Name

Date of Birth

MaleFemale

Name

Date of Birth

MaleFemale

Name

Date of Birth

MaleFemale

Name

Date of Birth

MaleFemale

Name

Date of Birth

MaleFemale

Name

Date of Birth

Father's full name

Father’s occupation

Mother’s full name

Mother’s maiden name

Mother’s occupation

Full Name of Next of Kin

Phone

Address

Full Name of Executor

Phone

Address

Full name of Doctor

Phone

Address

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

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

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