Testing Purposes

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1Choose Location

2Your Details

3Deceased's Details

4Deceased's Family Details

5The Application for Cremation

6The Authority to Cremate

7Additional Details & Signing

8Final Check

Choose the location for your Cremation

Estimated Price

Your Details

Your Name

The name of applicant

First Last

Your Address

The Applicant's Address

Street Address Suburb State Post Code Country

Your email

The applicant's email

Your Phone

Applicant's date time phone number

Your Occupation

Details of the Deceased

Name of deceased

First Last

Name at birth

If different from above

Birth first name Birth last name

Date of Birth

DD slash MM slash YYYY

Age

Gender / Sex

Address of Deceased

Street Address Suburb Region Post Code Country

Date of Death

DD slash MM slash YYYY

Approx Time of Death

Place of Death

To the best of your knowledge, give the location address and say whether its your own residence, lodging, hotel, hospital, nursing home etc

Usual Occupation, Profession or Job

Was the deceased descended from a NZ Maori?

Yes

Which ethnic group did the deceased belong to?

Living Children of the Deceased

Ages of Living Daughters

Ages of Living Sons

Parents of the Deceased

Mother's Name

Mother's Birth Name

Mother's name at birth if different from above

Mother's Birth Surname

Mother's Occupation

Father's Name

Father's Birth Name

Father's name at birth if different from above

Fathers's Birth Surname

Father's Occupation

Relationship Details of the Deceased

Relationship status at time of death

Married

Divorced

Seperated

Never Married

Widow/er

Most recent relationship

Recent Spouse or Partner's full name

Spouse or Partners surname at birth

Place of marriage or civil union

Age of deceased at time of marriage / civil union

Sex of Spouse / Partner

Age of Spouse / Partner (if living)

Application for Cremation Questions

The true answers to the questions set out below are as follows:

Are you an executor of the deceased?

Yes

Are you a relative of the deceased?

Yes

If so, state the relationship:

If you are not an executor or a near relative state why this application is being made by you and not by an executor or near relative:

The term “near relative” as used in this form, means the wife or husband of the deceased, a parent of the deceased, or a child of the deceased who is over the age of 16 years; and includes any other relative of the deceased who usually resides with them.

Have the near relatives of the deceased been informed of the proposed cremation?

Yes

If the application is not made by an executor, is there an executor of the deceased?

Yes

If there is an executor, has he/she been informed of the proposed cremation?

Yes

If there is an executor please state their name and address:

To the best of your knowledge and belief has any near relative or executor of the deceased expressed any objection to the proposed cremation?

Yes

If so, on what ground?

Do you know or have any reason to suspect that the death of the deceased was due to:

Violence

Yes

Poison

Yes

Privation or neglect

Yes

Illegal operation

Yes

Do you know of any reason whatever for supposing that an examination of the body of the deceased may be desirable?

Yes

Do you know or have any reason to suspect that the body of the deceased contains a cardiac pacemaker or other biomechanical aid?

Yes

Do you know or have any reason to suspect that the body of the deceased contains a Cardiac Pacemaker or other Biomechanical Aid?

Yes

Give the name and address of the usual medical attendant of the deceased

Give the names 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?ttended the deceased during his/her last illness

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?

Yes

If so, give the name by which that religious denomination is known

Following cremation my instructions in relation to the ashes are:

I hereby certify, with a view to procuring the Cremation of the body of the above-named Deceased, that all particulars stated above are true, and that to the best of my knowledge and belief no information has been omitted.

Yes

The Authority to Cremate

I declare that I am authorised to give this authority and fully indemnify you against any and all claims, costs, damages and/or proceedings arising from any matter, services and/or attendances arising from this agreement.

I authorise you to pay on my behalf all costs in connection with the funeral arrangement from the date of this agreement.

Yes

I acknowledge that I may be requested to and if so will pay the external or third party funeral expenses, relating to this financial agreement, in advance. I may also be required to pay for all or part of the services in advance of the services being provided and you will not be obliged to perform the services where such requested payment is not forthcoming (time being of the essence).

Yes

I understand that your account will be dated day of the cremation and will be emailed on the day of cremation.

Yes

The due date for full payment is on invoice date. After this date this account becomes overdue and I am liable to pay any late payment penalties charged and calculated at 1.25% per month on the closing monthly balance including any late payment penalties. The late payment penalty fee has been agreed between us to take into account a genuine pre-estimate of the costs of enforcement, collection costs and additional administration costs. For the avoidance of doubt, no credit is extended in respect of late payment of your account and any late payment penalty fee.

Yes

I understand that you may use any of my/or the deceased’s information for your credit and administrative purposes. I hereby consent to you undertaking any credit checks/enquiries with any third party you consider necessary and I consent under the Privacy Act 1993 to you collecting, retaining and using any personal information that may arise from your enquiries for the purposes for which it was collected.

Yes

I understand that if the account remains unpaid beyond the date of invoice, you may, at your discretion, take steps to recover the amount unpaid (including assigning the benefit of this agreement to a collection agency of your choice) and I am liable for those associated costs.

Yes

The terms of payment are not subject to the granting of probate, reimbursement under any compensation funds (statutory or otherwise), or payment of any insurance claim.

Yes

This is an estimate only as additional requirements may or may not be requested following the signing of this agreement.

Yes

Estimated Fee for this Service

Intended method of payment

You'll be contacted with a confirmation of costs before payment is due

Bank Transfer

Credit Card

Cheque

Cash

Any additional details?

Signature of Applicant

Date

DD slash MM slash YYYY

Witness to Signature

Witness Name

First Last

Witness Occupation

Witness Address

Street Address Suburb Region Post Code Country

Final Check before submitting {all_fields:nohidden}

Testing Purposes

Your Details

Details of the Deceased

Living Children of the Deceased

Parents of the Deceased

Relationship Details of the Deceased

Application for Cremation Questions

The Authority to Cremate

Get in touch

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