Customer Number:
I [Full Name Applicant]
Date:
To be interred in:
Full name of person(s) currently interred in the plot:
Of [Address]
Area/Section: Block: Row: Plot:
1: Date of Death:
2: Date of Death:
PLEASE NOTE: If parties are deceased or unavailable then a new burial rights holder will need to be assigned to act on behalf.
Of [Last Address]
I am the [Relationship] to the deceased.
Being the person responsible for the plot, hereby give permission for the late:
[Name of Deceased]
At:
This form MUST be completed before a plot is opened with relevance too
• Pre-purchased plot (not utilised)
• Re-opening an existing plot (utilised)
Cemetery
BURIAL RIGHTS HOLDER
APPLICANT SIGNATURE
PLOT DETAILS
1
3
2
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:
Page 1/1 // August 2015
AUTHORITY TO
OPEN A PLOT
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
click to sign
signature
click to edit
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