Please Read Before Filling In This Form

The information you provide us in this form is used to supply you with the official Death Certificate from Qld Births, Deaths and Marriages Office (BDM). The information needs to be filled out fully and correctly to enable us to complete the paperwork without delay ensuring you receive the Death Certificate within 3-4 weeks of funeral.

If the information is incorrect and a change to the Death Certificate is required a further cost of $19.95 payable to BDM may be required.

Details of person completing the Pre-arrangement form

Authorised Person's Name (name of person completing this form)*

Relationship To Deceased*

Email Address*

Your Mobile Phone Number

Your Home or Work Phone Number

Address

Street Address

Suburb

State

Postcode

Country AustraliaUnited State

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Deceased Person's Details

First Name*

Surname*

Date of Death*

Place of Death*

Sex*

Malefemale

Date of Birth*

Normal Address

Street Address

Suburb*

State

Postcode*

Country

Usual Occupation When Working

Retired*

YesNo

Place of Birth* (Town/City, State and Country)

If born overseas, in what year did the subject person first arrive in Australia

Is the subject of Aboriginal or Torres Strait origin*

NoAboriginalTorres Strait IslanderAboriginal and Torres Strait Islander

Is there a pacemaker or defibrillator present?*

YesNo

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Current Marital / Civil Partnership Details

Marital Status

Civil PartnershipCivil Partnership Terminated DefactoDivorcedMarriedNever MarriedRegistered RelationshipWidowedUnknown

Number of Marriages / Civil Partnerships:

Town/City & State/Country of most recent union:

Deceased's Age In Years At Date Of Marriage / Civil Partnerships

First Name of Spouse or Civil Partner

Surname of Spouse or Civil Partner

Was the deceased person previously married or joined in civil union(s)?

YesNo

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Parent's Details

Father's First Name*

Father's Surname*

Father's Occupation

Mother's First Name*

Mother's Maiden Surname*

Mother's Occupation

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Children's Details

Number of children born to the subject person.

Child's Given Name.

Date of Birth

Deceased Child is deceased

Child's Given Name.

Date of Birth

Deceased Child is deceased

Child's Given Name.

Date of Birth

Deceased Child is deceased

Child's Given Name.

Date of Birth

Deceased Child is deceased

Child's Given Name.

Date of Birth

Deceased Child is deceased

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Funeral Wishes

Funeral Type*

Civil PartnershipCivil Partnership Terminated DefactoDivorcedMarriedNever MarriedRegistered RelationshipWidowedUnknown

Venue of Funeral*

At Cemetery / Crematorium onlyAt Church with procession to Cemetery / CrematoriumNo service requiredAnother venue (nominate specifics below)

Which Crematorium?

Service By

Church officialOur celebrant

Religion / Denomination (if any)

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Other Requirements

Will a Newspaper Notice be required/*

YesNo

Will a free Facebook tribute be required/*

YesNo

Will the Flag and/or Last Post be required/*

YesNo

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Authorisation

Authorised Person*

I, the Authorised Person noted above, hereby certify that I am legally entitled to give the above instructions and indemnify Michael Hutchinson Funeral Director from any legal proceedings resulting from my not being the person legally entitled to give the above instructions. I agree

YesNo

Payment I agree to pay Michael Hutchinson Funeral Director the agreed full payment at least 24 hours before the funeral occurs only by credit card or electronic transfer. I agree

YesNo THE PAYMENT CAN ONLY BE MADE BY CREDIT CARD BY CALLING 3273 1399 OR ELECTRONIC TRANSFER TO OUR BANK ACCOUNT - WESTPAC ACCOUNT BSB 032-044 ACCOUNT NUMBER 772711 AND NOT BY MAIL OR IN PERSON. PLEASE BE AWARE THAT WE DO NOT BILL SOLICITORS, TRUST OFFICES OR ANY OTHER THIRD PARTIES.

Terms and Conditions I acknowledge that I have read and understand the Terms and Conditions and confirm that the information provided is to the best of my knowledge and belief, true, accurate and not misleading. I agree

YesNo

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Please Assist Us

Where did you find us?* —Please choose an option—Google SearchInternet Banner AdHospital / Nursing HomeFamily / Friend RecommendationPrevious CustomerNewspaperYellow PagesDeceased PrearrangedChurch

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