Pre-arranged Funeral Form

Your Personal Details

Name*

First Last

Your Contact Phone Number*

Email Address*

Gender

Male
Female

Date of Birth (DD/MM/YYYY)

Your current residential address

Street Address City State Post Code Country

Occupation

If you are retired, please let us know your old occupation

Are you retired?

Yes
No

Place of birth (Town, City, State)

If born overseas- what was your last year of arrival in Australia?

Are you an Indigenous Australian?

Yes
No

Are you an Torres Straight Islander?

Yes
No

Your Marriage History

Current Marital Status

Please list all marriages starting with your first

Place of Marriage (Town, State, Country)	Your age at date of marriage	Full name of spouse

Have you had more than one marriage?

Yes
No

Details of your second and subsequent marriages

Place of Marriage (Town, State, Country)	Your age at date of marriage	Full name of spouse

Do you have any children?

Yes
No

Your Children

Enter your children below:

First Names	Second Names	Date of Birth (DD/MM/YYYY)

Enter in order of birth. If deceased Enter “D” in "Date of Birth" column. If not born alive (Stillborn) enter “SB” in "Date of Birth" column. Click the + button to enter more names.

Your Parents

Your Father

Your Fathers full name	Your Fathers occupation

Your Mother

Your Mother full name	Your Mothers occupation

Your Funeral Preferences

We will email you shortly with a form that allows you to select your preferences based on the service that you have chosen.

What type of service would you like?

Burial Service
Cremation Service
Repatriation

Repatriation Service

Please return my body to:

Preferred Funeral Director in that Country:

Please add any comments in the box below

Burial/Cremation Service

I would like to be:

Buried
Cremated

Please nominate preferred cemetery and grave number if pre-purchased

Please nominate preferred crematorium

I would like my ashes to be:

Scattered
Buried
Returned to

Please nominate where you would like your ashes to be scattered

Please nominate where you would like your ashes to be buried

Please nominate where you would like your ashes returned

I Would Like My Funeral Service

Held at the Church and then the graveside / Crematorium
Held entirely at the Graveside / Crematorium
Church only with no attendance at the graveside or crematorium

I would like Academy Funerals to provide a

Civil Celebrant
Priest / Minister

If known, what is the name of the celebrant or Minister you would like to do your funeral?

Please state required religion

Coffin/Casket Selection

Which coffin would you like?

Solid Timber
Medium density fibreboard
Wicker

OR which casket would you like?

Solid Timber
Metal

Funeral Details

I would like to be dressed in:

I would like to wear the following jewellery:

Please return any jewellery that I may have on my person to my family:

Yes
No

Flowers and Other Details

Would you like to have flowers? If so which type:

No thank you, I do not want flowers
I would like native flowers
I Would like mixed seasonal flowers
I would like a particular flower at my funeral

Let us know the name of the particular flower you wish to be at your funeral:

I would like my flowers to be taken home by my family

Yes
No

I would like an order of service printed for my service

Yes
No

I would like Bookmarks printed for my service

Yes
No

I would like Doves released at my funeral

Yes
No

I would like butterflies released at my funeral

Yes
No

I would like a piper to play at my funeral

Yes
No

I would like a professional singer at my funeral

Yes
No

I would like the RSL to take part in my funeral

Yes
No

I would like the Last post played LIVE at my funeral (Extra cost)

Yes
No

I would like a recorded version of the Last post played at my funeral

Yes
No

I would like the Mason’s or other group to take part in my funeral

Yes
No

If you would like a country flag placed on your coffin/casket, please specify country:

I would like the following music played:

I would like a DVD presentation of my life played:

Yes
No

Please place a funeral notice for me in the:

Please advertise my funeral on the Polynesian Funerals Website, Facebook and Funeral Zone

Yes
No

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