Contact Information Contact information for either the person to whom this form relates or a family member/friend. Name of person completing this form * Relationship to the individual named below (if not completing for yourself) Phone — a family member's number can be used * (###) ### #### Email — a family member's email can be used * Section 1: Personal Information Details pertaining to the individual for whom this form is intended. Title Mr Mrs Ms Miss Dr Reverend First/given name(s) * First Name Last Name Name(s) at birth — if different from above First Name Last Name Date of birth MM DD YYYY Place of birth Country of birth If NOT born in New Zealand, what was your date of arrival to New Zealand MM DD YYYY Usual occupation/profession Usual home address Address 1 Address 2 City State/Province Zip/Postal Code Country Descended from NZ Maori? Yes No Don't know Are you any of the following — select all that apply Marriage Celebrant Civil Union Celebrant Justice of the Peace Section 2: Parent’s details Mothers name(s) First Name Last Name Mother’s name(s) at birth — if different from above First Name Last Name Mothers occupation Fathers name(s) First Name Last Name Father’s name(s) at birth — if different from above First Name Last Name Fathers occupation Section 3: Most recent relationship details Most recent relationship Married Civil Union Divorced De Facto Widowed Separated Never in a legal relationship Place of marriage/union Age at time of marriage/union Spouse/partner’s full name — immediately prior to marriage/union First Name Last Name Spouse/partner's date of birth MM DD YYYY Spouse/partner's gender Male Female Spouse/partner’s current status Living Deceased Daughter(s) age(s) — if deceased note age at time of death followed by ‘D’ Son(s) age(s) — if deceased note age at time of death followed by ‘D’ Section 4: Second most recent relationship details — if applicable Second most recent relationship Married Civil Union Divorced De Facto Widowed Separated Never in a legal relationship Place of marriage/union Age at time of marriage/union Spouse/partner’s full name — immediately prior to marriage/union First Name Last Name Spouse/partner's date of birth MM DD YYYY Spouse/partner's gender Male Female Spouse/partner’s current status Living Deceased Daughter(s) age(s) — if deceased note age at time of death followed by ‘D’ Son(s) age(s) — if deceased note age at time of death followed by ‘D’ Section 5: My funeral choices I direct that I am to be Cremated Buried My funeral is pre-arranged Yes No My funeral is pre-paid Yes No I have funds to cover my funeral Yes No I need more information about costs Yes No My funeral service is to be held at Preferred cemetery/crematorium Plot details — if any Casket choice — if known Ashes placement Scatter Inter Preferred Priest/Minister/Celebrant to officiate at my service Flower choices Hymns or song choices Readings — Bible verse, poems etc. Pallbearers Other special instructions Contact details of friends/clubs/organisations you would like to be advised Next of kin name and contact details Death notice to be placed in the following paper(s) Name of lawyer/solicitor Service record — if applicable Service number Rank Unit/regiment Overseas/New Zealand service details Which conflict Thank you for completing in our pre-arrangement questionnaire. A Hope Funerals team member will be in touch shortly. Pre-Arrangement Questionnaire
