Full name of applicant
*
First Name
Last Name
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
Full name of deceased
*
First Name
Last Name
Last known address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
Age
Gender
Male
Female
Neutral
Relationship status
*
Married
Widower
Widow
De Facto
Civil Union
Never married
Are you an executor of the deceased?
Are you a relative of the deceased?
If so, state the relationship
If you are not the executor or a near relative, state why this application is being made by you and not by an executor or a near relative
Have all the near relatives of the deceased been informed of the proposed Cremation?
If the application is not made by the executor, is there an executor of the deceased?
To the best of your knowledge and belief, has any near relative or executor of the deceased expressed any objection to the proposed Cremation?
*
Date
*
MM
DD
YYYY
Time
*
New Zealand time
Hour
Minute
Second
AM
PM
Where did the deceased die?
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Was the address own address, lodging, hotel, hospital or nursing home?
*
Do you know or have any reason to suspect that the death was due, directly or indirectly, to: (tick any that apply)
Do you know any reason to whatsoever for supporting that an examination of the body of the deceased may be desirable?
*
Do you know or have any reason to suspect that the body of the deceased contains a cardiac pacemaker or other biomechanical aid?
Name of the ordinary medical attendant of the deceased
*
First Name
Last Name
Address of the ordinary medical attendant of the deceased
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Give the names and addresses of all the medical practitioners who attended the deceased during his/her last illness
Who were the persons (if any) present at the time of death?
Was the deceased a member of a religious denomination whose tenets require the burning of the body to be carried out as a religious rite elsewhere than in an approved crematorium?
*
If you responded yes to the above, give the name by which that religious denomination is known:
I have been advised of the list of items prohibited for cremation and agree to make sure none of these items are included in the casket, or they can be easily removed prior to cremation. I HEREBY CERTIFY, with a view to procuring the cremation of the body of the above-named deceased, that all the particulars stated above are true, and that to the best of my knowledge and belief no material particular has been omitted.
*
Date signed
MM
DD
YYYY
Witness's name
*
First Name
Last Name
Witness's signature
Witness's occupation
Witness's address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Authorisation of Funeral Director: I have authorised the following Funeral Director to act on my behalf in relation to this cremation
*
