Sometimes, in life, we will all experience the loss of a loved one through death, or even help a friend through this traumatic period. In the midst of grief someone has to take on the responsibility of arranging a funeral.

This form is designed to record important information that will aid your family at the time of death. We suggest that you spend a few moments filling in this form. The time spent now could save much upset, distress and misunderstanding later. It will also ensure that your wishes are carried out in accordance with your instructions.

Please print and complete this form and return it to Victor Rullis Funeral Services so we can record your wishes.

If you have any problems completing this form, please contact us at any time.

This form is not meant to offend, only to assist.

This information is necessary for registration when death occurs.

Full Name:	...................................................
Occupation:	...................................................
Address:	...................................................
Date of Birth:	...................................................
Contact Phone:	...................................................
Father's Name:	...................................................
Mother's Full & Maiden Name:	...................................................
Name of Spouse (including maiden name):	...................................................

Are you in receipt of any of the following pensions (please circle):

Age/Invalid - Widows - Service/War

Pensions Number, if pensioner:

...................................................

Marriage Details

First Marriage:
Place:	.................................................................
Date:	.................................................................
To Whom:	.................................................................

(including maiden name)

Second Marriage:
Place:	.................................................................
Date:	.................................................................
To Whom:	.................................................................

(including maiden name)

Full names of all the children (including stillborn and deceased) and their dates of birth (if deceased, state so in lieu of date of birth).

1................................................................	D.O.B............................................................
2................................................................	D.O.B............................................................
3................................................................	D.O.B............................................................
4................................................................	D.O.B............................................................
5................................................................	D.O.B............................................................

It is my wish that my funeral arrangements are as follows:

Burial or Cremation?	.................................................................
Cemetery/Crematorium?	.................................................................
Church, Chapel or Graveside Service?	.................................................................
Minister or Funeral Celebrant?	.................................................................
Floral Tribute?	.................................................................
Newspaper or Radio Notice?	.................................................................
Religion?	.................................................................
Mourning Car?	.................................................................
Special Request? Hymns, Music, Pall Bearers, Eulogy etc.	.................................................................
Are you a Returned Service person?	.................................................................
Member of a Lodge, Club or Society?	.................................................................
Next of Kin & Relationship to you?	.................................................................
Address:	.................................................................
Phone:	.................................................................
Name & Address of Medical Practitioner:	.................................................................
	.................................................................

Authority
I hereby authorise Victor Rullis Funeral Services to carry out my funeral arrangements.

It is my wish that my funeral arrangements are as stated:

Signed:	.................................................................
Dated:	.................................................................