I wish to prearrange:

An at need funeral (today's prices)
Prepaid funeral with payment over 3 years
Prepaid funeral with one lump sum
Pre-arranged Funeral Only (no funds prepaid)
Prearranged funeral and paying in instalments from $50 per month

First Name:
Middle name(s):
Last name:
Name you prefer to be called:

Current residential address:
Suburb:	State ACT NSW VIC QLD SA WA TAS Postcode:
E-mail address:
Phone:	Mobile:

Full name:

Current residential address:
Suburb:	State ACT NSW VIC QLD SA WA TAS Postcode:
E-mail address:
Phone:	Mobile:

Full Name:

Current residential address:
Suburb:	State ACT NSW VIC QLD SA WA TAS Postcode:
E-mail address:
Phone:	Mobile:

My will is lodged with:
My solicitor is:
I have a funeral plan with:
I have Life Insurance with:
My family doctor is:

This information is required to register a death with the Registry of Births, Deaths, and Marriages

Gender:

Male

Female

Date of birth:
Usual occupation:
Birthplace:	Town: State: Country:
Period of residence:	All my life	From (year)
Do you have Aboriginal or Torres Strait Islander descent?		Yes No
Marital status:	Never Married Married Widowed Divorced Separated
Previously married	Yes	No
Family details:	Father's name:
	Father's occupation:
	Mother's name:
	Mother's maiden name:
	Mother's occupation:
Current marriage details:	Place of marriage:
	Age when married:
	Spouse's name:
Previous marriage details:	Place of marriage:
	Age when married:
	Spouse's name:

Children: (write 'D' after birthdate if child now deceased)	Name:	Birthdate:
	Name:	Birthdate:
	Name:	Birthdate:
	Name:	Birthdate:
	Name:	Birthdate:
	Name:	Birthdate:
	Name:	Birthdate:
	Name:	Birthdate:
	Name:	Birthdate:
	Name:	Birthdate:

Public or private:	Public	Private
Venue:	Church	Our Chapel
	Crematorium Chapel	Graveside
	Other (please indicate)
Viewing:	Yes No	Family to decide
Clergy or Celebrant:	Clergy	Denomination:
	Celebrant	Male Female
Coffin or Casket:	Coffin	Casket
	Name (if decided):
Cremation or Burial:	Cremation
	Location:
	Ashes Placement:	Ashes scattering (sea)
		Ashes scattering (land)
		Ashes scattering (air)
		Internet in existing gravesite
		Send To:
		Other:
	Burial
	Location:
	Grave type:	Lawn grave
		Lawn monumental grave
		Monumental area
		Other
Newspaper Notices: (you can choose more than one)	The Courier-Mail (Brisbane)	Gold Coast Bulletin
	Tweed Daily News	Toowoomba Mercury
	Queensland Times	Other

RSL/Lodge/Clubs/Associations to be notified:

Contact Name:	Phone:
Contact Name:	Phone:
Contact Name:	Phone:
Contact Name:	Phone:

RSL service required:	Yes	No
Flag required:	Yes No	Country:
Music:	Musician (organist/soloist)	CD/tape
	Song Choice:
	Song Choice:
	Song Choice:
Flowers:	Casket spray	Posy/bouquet
	Single rose	Other
Donations:	Donations and flowers	Donations in lieu of flowers
	if applicable, donations to:
Vehicles:	Mourning car(s)	Limousines
Pall bearers:	Family or Friends	Funeral staff
Audio visual:	Audio tape the service	Video tape the service
	Multimedia photo slideshow	Basic photographs taken
Other options: (you can choose more than one)	Order of service	Prayer Cards
	Catering	Other
Other requests: