The information below includes that required by the Registrar-General of Births, Deaths & Marriages. Please complete fully to ensure your personal details are accurately recorded and your wishes followed.

PERSONAL PROFILE

PERSONAL DETAILSSurname/Family name

Mr/Mrs/Ms/Miss

First/Given names

Address

Birth place

Birth date

Surname at birth

First name given at birth

Ethnic group

Descended from NZ Maori? (Yes/No/Don’t know)

If not born in NZ, year of arrival in NZ?

Occupation/Profession

YOUR RELATIONSHIPSMost recent relationship status

Single/Married/Civil Union/De facto/Separated/Divorced/Widowed (record other marriages/unions on separate page)

Age when most recent marriage or union took place

Place of Marriage/Civil Union

Full name of Spouse/Partner

Spouse/Partner’s age (if living) Spouse/Partner’s sex (M/F)

FUNERAL DETAILSName & address of Next of Kin/Executor expected to make funeral arrangements (use reverse of sheet if more room required)

Name & address of Solicitor or other person holding the will

Venue of funeral service

Preferred Celebrant/Priest/Clergy

Are you:

Honours & Awards held

Military Service Number Rank Unit or Regiment

Overseas/NZ service Which war/country

Full name of Mother

Full name of Mother at birth

Mother’s occupation

Full name of Father

Full name of Father at birth

Father’s occupation

Names & dates of birth of living Daughters

Names & dates of birth of living Sons

Funeral director with whom funeral arrangements have been made

Prepaid funeral with

Burial? If burial, what is the plot site (if any)

New/Re-open

Cremation? If cremation where is the place where ashes are to go?

Scatter or Inter?

Flowers/Donations to

• Justice of the Peace? Yes / No

• Marriage or Civil Union Celebrant? Yes / No