Funeral planning form

This form helps you to think about all the information that we will ask you when we will talk about your funeral. We suggest you print a copy of it first or, if a printer is not available, we will return a copy to you (in duplicate) for your records.

We also suggest you give a copy to your next-of-kin so that they may acquaint themselves with the details recorded.

If you would like a funeral director to contact you regarding your pre-arrangement, please indicate this on the form. We respect your privacy, therefore no personal contact from Golden Bay Motueka Funeral Services will be made unless requested.

Any field that features a red asterisk (*) next to its title is a required field. If you do not know the answer to any required item, please enter the words "not known" so that the form may be properly submitted.

If you need help understanding any areas of the form, please feel free to contact us.

Personal Information
Full Name
Gender	Select Male Female
Date of Birth (dd/mm/yy)
Place of Birth
If Place of Birth is not New Zealand, when did you arrive in N.Z?
Address
Suburb and City
Occupation
Ethnic Group	Please select NZ Maori Samoan Niuean NZ European / Pakeha Cook Island Maori Chinese Other European (specifiy) Tongan Indian Other (specify)
If other, please specify
Living Children
Birthdate of each daughter
Birthdate of each son
Parents
Mother's full name
Mother's full name at birth
Mother's occupation
Father's full name
Father's occupation
Relationship Status
Relationship Status	Please select Married Civil union Recognised defacto relationship Separated Divorced Widowed Never married
If married, please fill in the fields below:
Spouse's full name
Spouse's maiden name
Your age at marriage
Place of marriage
If previously married, please fill in the fields below:
Spouse's full name (2)
Spouse's maiden name (2)
Your age at marriage (2)
Place of marriage (2)
If there were earlier marriages, please list the above details for each
Funeral preferences
Place of Service	Please select Golden Bay Motueka Chapel Golden Bay Motueka Chapel Golden Bay Motueka Chapel Church Crematorium Chapel Other
If other, please specify
Religious denomination
Officiant	Select Priest/Minister Civil Celebrant Relative/Friend
Musical selections to be played
I will supply a CD	yes   no
Musical selections to be sung
Favourite Bible passages
Favourite literature or poems
Favourite flowers
Favourite flower colours
Final disposition	Select Burial Cremation Burial at sea Other
If other, please specify
Plot owned	yes   no
Plot cemetery reference
Next of Kin / Executor
If a Next of Kin or Executor is available, please include their name and daytime contact details
Pre-Paid Funerals
I have arranged a Prepaid Funeral with
I would like to receive information about Prepaid Funerals	yes   no
Further comments
Please record any other wishes or preferences that are not explicitly catered for above.
Please mail a printed copy of this information to me	yes   no
Contact information If you would like Golden Bay Motueka Funeral Services to contact you regarding your pre-arrangement, please fill out your daytime contact details below. No personal contact from Golden Bay Motueka Funeral Services will be made unless the contact information below is complete; therefore, if you do not desire to speak with a Funeral Director, leave these fields blank.
Daytime telephone number
Email Address
Submit or print the form Once you have completed all relevant fields, you can either print this form (choose 'Print' from the 'File' menu) or press the 'send' button below to send the form to us. Golden Bay Motueka Funeral Services respects your privacy; your information is confidential and will not be shared with third parties.