Online Pre-Arrangement Form

Person completing the form

Email*

Please contact me—Please choose an option—YesNo

Funeral Arrangements for

Contact Phone No

Funeral Service

It is my desire that my Funeral Service should be held at: (Chapel, Church, Cemetery, Crematorium or other venue).

Venue Name

Address

Existing burial arrangements

I have an allotment at (cemetery)

Grave Details

or new burial arrangements

Please arrange a burial at (cemetery)

or cremation details

I wish to be cremated at

And that my ashes be

Newspaper Notice placed in

Donation envelopes—Please choose an option—Not specifiedNo - please do not display at the serviceYes - please display envelopes at the service

Charity Name

Flowers for the coffin/casket

Type of arrangement

Information required by law

My given names are

My Surname is

My date of birth is

Sex—Please choose an option—Not specifiedMaleFemale

My Current Address is

My Phone Number

My Usual Occupation

I was born at

Do you receive a pension?—Please choose an option—Not specifiedNoYes

If so which type?—Please choose an option—Not specifiedNilOld AgeMilitaryInvalid

My parents information

My Fathers given names

My Fathers surname

My Fathers occupation is/was

My Mothers given names

My Mothers maiden name was

My Mothers occupation is/was

My marital information

My present marital status—Please choose an option—SingleMarriedDe FactoDivorcedWidowWidowerSeparated

If Widowed please state

Date of death of Spouse

Place of death of Spouse

First marriage

Spouse's given names

Spouse's surname

I was married at

My age when married, years

Second marriage

Spouse's given names

Spouse's surname

I was married at

My age when married, years

Third marriage

Spouse's given names

Spouse's surname

I was married at

My age when married, years

My childrens' information

The names and ages of my children are as follows. (Please place a 'D' in the age field if your child is deceased):

First child
 

Second child
 

Third child
 

Child four
 

Child five
 

Child six
 

Child seven
 

Child eight
 

Other details

I would like the following persons notified of my passing

First person
 

Second person
 

Third person
 

My documents

My will is lodged with

My Solicitor is

I have a funeral benefit plan with

I have a Life Insurance policy with

Anything else?

Specific Requests

or