Fillable Form 1: BURIAL & ASH INTERMENT APPLICATION FOR (Queenstown Lakes District Council New Zealand)

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Form 1: BURIAL & ASH INTERMENT APPLICATION FOR (Queenstown Lakes District Council New Zealand)

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The Form 1: BURIAL & ASH INTERMENT APPLICATION FOR (Queenstown Lakes District Council New Zealand) form is 3 pages long and contains:

  • 3 signatures
  • 34 check-boxes
  • 54 other fields

Country of origin: NEW-ZEALAND
File type: PDF

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Burial Ash Interment Double Ash Interment
Day:
Area/Section:
BURIAL: ASHES:
Date:
Block:
Arrival Time:
Plot:
AM / PM
Mr Mrs Ms Miss
New Plot Pre-purchased plot* Reopen*
*A pre-purchased plot or reopen also requires the authority to open a pre-purchased or occupied plot form.
*Please note: A medical certicate or Coroner’s Authorisation must be provided.
Gender: Male Female
Medical Certicate received* Coroner’s Authorisation received*
Surname:
Residential Address (last known):
Forename/s: Known As:
Date of Birth:
Date of Death:
Nationality:
Place of Birth:
Place of Death:
Religion:
Age: Occupation:
At: Cemetery
APPLICATION FOR
BURIAL BOOKING DETAILS
PLOT DETAILS
INTERMENT TYPE
DECEASED’S DETAILS
1
3
5
4
2
Single Depth 1st Interment
2nd Interment 3rd Interment
Double Depth 2nd Interment
1st Interment
4th Interment
Casket/Urn Size (mm): Length Width Height
Casket/Urn Shape:
CASKET/URN DETAILS6
Page 1/3 // March 2019
APPLICATION FOR
BURIAL & ASH
INTERMENT
(Ofce Use) Customer Number:
Expected number of attendees at Cemetery:
GRAVESIDE DETAILS
SPECIAL INSTRUCTIONS
7
8
Name:
Mr Mrs Ms Miss
Mr Mrs Ms Miss
Company:
Surname:
Surname:
PLEASE NOTE: QLDC will send an invoice for the costs of interment directly to the “next of kin” named above, unless
otherwise stated. Payment must be made BEFORE a burial is conrmed.
Residential Address:
Billing Address:
Phone:
Date:
Date:
Date:
Email:
Forename/s:
Forename/s:
Signature:
Signature:
Signature:
Phone:
Phone:
Relationship to Deceased:
Relationship to Deceased:
Mobile:
Mobile:
Email:
Email:
FUNERAL DIRECTOR’S DETAILS
PURCHASER OF BURIAL RIGHTS DETAILS (NEXT OF KIN)
BILLING DETAILS (IF DIFFERENT FROM ABOVE)
9
10
11
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wanaka
P:
QUEENSTOWN 03 441 0499
P: WANAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 2/3 // March 2019
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Charges: Plot Purchase $
Excavation Fee $
Maintenance $
Oversize $
Other $
Completed Forms:
Authority to open a plot received
Yes No
Medical Certicate or
Coroner’s Authorisation received
Yes No
Payment: Charge to FD
Charge next of kin
Queenstown Lakes District Council will use personal information for the purposes for which it was collected, or as otherwise authorised
by the Privacy Act 1993 or any other legislation. The Council will share personal information with the Council’s contractors and agents for
the purposes of complying with the Council’s obligations, and carrying out its functions under the Burial and Cremation Act 1964. In all
other cases the Council will not share personal information with any third parties unless written permission is given by next of kin, or unless
authorised by the Privacy Act 1993 or any other legislation.
PRIVACY STATEMENT:
OFFICE USE ONLY:
Private Bag 50072, Queenstown 9348
10 Gorge Road, Queenstown 9300
47 Ardmore Street, Wanaka
P:
QUEENSTOWN 03 441 0499
P: WANAKA 03 443 0024
E: services@qldc.govt.nz W: www.qldc.govt.nz
Page 3/3 // March 2019
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Form 1: BURIAL & ASH INTERMENT APPLICATION FOR (Queenstown Lakes District Council New Zealand)

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Completed 11 February 2021

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