Applicant - The Person the Plan is For Name* Please leave this field empty. Address* Phone* Mobile* Email* Next of kin Name Address Phone Mobile Relationship* Second Contact Correspondence To Funeral Plan Details Service Preferred Service Location ---Heritage ChapelGraveside at CemeteryChurch with cortege to cemetery / crematoriumChurch followed by private burial / cremationChurch only with no cortegeMemorial service onlyNo service requiredAnother venue Venue If Re-open grave, name of person previously buried If Re-open grave, date of previous interment Pre-Paid Details Crematorium Ashes to be Denomination Clergy/Celebrant Specific Requests Press Notices Prefer donations to Flowers Music Selection Organist/Singer Readings/Poems Leaflets Photo Tribute Catering Memorial Book Other Requests Coffin/Casket Chosen Material Colour Cross or Crucifix (please specify requirements) Pre-Paid Funeral Fund Personal & Family Information Date of Birth* DD/MM/YYYY - eg. 09/06/1664 Place of Birth* If born overseas, when did you arrive in Australia?* YYYY - eg. 1964 Are you of Aboriginal Origin?* ---YesNo Are you of Torres Strait Islander Origin?* ---YesNo Usual occupation during working life* Marital status ---Never marriedMarriedDivorcedWidowedCivil PartnershipDe FactoUnknown Marriage Details - (1st) Place of Marriage Town, State, Country Age when married Years Name of Spouse Full name at date of marriage Marriage Details - (2nd) Place of Marriage Town, State, Country Age when married Years Name of Spouse Full name at date of marriage Marriage Details - (3rd) Place of Marriage Town, State, Country Age when married Years Name of Spouse Full name at date of marriage Parent Details Father's Full Name Father's usual occupation during working life Mother's Full Name Mother's Maiden Surname Mother's usual occupation during working life Children Details First Childs Name If deceased write D, if stillborn write SB after the name please First Childs DOB DD/MM/YYYY - eg. 09/06/1664 Second Childs Name If deceased write D, if stillborn write SB please Second Childs DOB DD/MM/YYYY - eg. 09/06/1664 Third Childs Name If deceased write D, if stillborn write SB please Third Childs DOB DD/MM/YYYY - eg. 09/06/1664 Fourth Childs Name If deceased write D, if stillborn write SB please Fourth Childs DOB DD/MM/YYYY - eg. 09/06/1664 Fifth Childs Name If deceased write D, if stillborn write SB please Fifth Childs DOB DD/MM/YYYY - eg. 09/06/1664 Sixth Childs Name If deceased write D, if stillborn write SB please Sixth Childs DOB DD/MM/YYYY - eg. 09/06/1664 Seventh Childs Name If deceased write D, if stillborn write SB please Seventh Childs DOB DD/MM/YYYY - eg. 09/06/1664 Eighth Childs Name If deceased write D, if stillborn write SB please Eighth Childs DOB DD/MM/YYYY - eg. 09/06/1664 Statement of Acknowledgement I hereby certify that the information I have provided is true and accurate to the extent of my knowledge and I accept that this is application is subject to approval* Send This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply. In this sectionHow to BeginFixed Price Pre-Payment of Funeral ExpensesCommon QuestionsPre-Planning FormTestimonials Thank you for making our memories of Dad’s service so special. The kindness of the staff in helping us, nothing was too hard. I can’t find enough words to thank you. Kerri
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