This form has been prepared in two secions, Section A covers Personal Details, and Section B covers your Funeral Needs.
Title * MrMrsDrMissMs
Given Names *
Surname *
Address *
Phone Number *
Email Address *
Place of Birth *
Date of Birth *
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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
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
Full name of Doctor
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
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
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.
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