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2. Funeral Pre Arrangement Details Form

2. Funeral Pre Arrangement Details

P R E – A R R A N G E M E N T D E T A I L S F O R M We suggest that when you have filled this form in and had a discussion with a funeral director, to nominate and tell a family member of your plans, and where this form will be kept. This will ensure that your wishes will be honoured when our family serves yours… Personal Details Date of Arrangement: DETAILS OF APPLICANT Funeral Arranger: DoB: Age: Disposition: Crem Burial Sex: M F Title: First Name/s: Surname: Names at Birth: Contact Phone: Alt. Contact: Venue/Urupa: Public Cemetery: Y N Name of Cemetery/Urupa: Surname at Birth: Residential Address: Suburb: City: REGISTRATION DETAILS Place of Birth: Country if not NZ: Years Lived in NZ: NZ Māori: Y N Ethnic Group: Occupation: Age of each living Daughter: Mothers First Name: Mothers First Name at Birth: Fathers First Name: Fathers First Name at Birth: Age of each living Son: Mothers Surname: Mothers Surname at Birth: Fathers Surname: Fathers Surname at Birth: RELATIONSHIP STATUS: Married In a De Facto Relationship Marriage/CU Dissolved Permanently Separated In a Civil Union Never in a Legal Relationship Spouse/Partner Decease* Separated from De Facto *If spouse/partner decease please indicate if married, or de facto relationship Partners First Name: Partners Surname: Male Female Partner Alive Deceased Partners DoB: Age at Marriage: JP or Marriage Celebrant: Yes No Honours Held: Yes No Name of Award: NEXT OF KIN CONTACT: Next of Kin Name: Address Details: Contact Number & Email: My Next of Kin/Executor to my Funeral is… Please note that this arrangement will be kept safe on file at the funeral home and this information may be shared with our Insurance Partner, AIL New Zealand for the purposes of assessing eligibility for funeral cover packages. All information is protected by the Privacy Act 1993.

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