Application for Interment
Family Name:
First name/s:
(as appears on the Death Certicate)
Gender: Late Residence:
Occupation: Date of Birth:
Place of Birth: Age:
Date of Death: Place of Death:
Religion: Marital Status:
Details of Deceased
Cemetery and Plot Details
Interment Details
Queen Street, P O Box 404, Te Kuiti 3941, NZ. Telephone 07-878 0800, Fax 07-878 7771, Email info@waitomo.govt.nz, Website www.waitomo.govt.nz
Ofce Use Only
*Please note by signing this form you hereby accept responsibility for payment of all charges to Waitomo District Council.
Please return form via email info@waitomo.govt.nz, Fax 07 878 7771 or post to P O Box 404, Te Kuiti, 3941
Cemetery: Date of Interment:
Time of Service: Time of Interment:
CSO Advised: Cemetery Book Updated: Payment Received:
ISU Manager Advised: Cemetery Plan Updated:
Receipt Number:
Warrant Issued: Cemetery Database Updated:
CSO Signature:
Plot Type:
(please tick)
New Plot Reserved Plot Plot Re-open
Area: Block Number:
Plot Number: Depth: Single Double
If Plot re-open, name of
rst interred:
Person giving authority to
open:
Type:
(please tick)
Ashes Burial
Casket Details:
(please tick)
Standard Size Oversize Ashes Urn
Special
Requirements:
Plot Title Deed to be in the
name of:
Full name of next of kin:
Address:
Relationship: Contact Number:
Funeral Company or
Family:
Contact Number:
Address:
Signature of
Applicant*
Date:
