mp-death registration form

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					                                           Registration of Death Information

The following information is required by the Registrar of Births, Deaths & Marriages

Deceased Person
Tick if applicable:           Aboriginal             Torres Strait Islander
Alias Surname/s:        1st                                               2nd
Given Name/s:
Alias Given Name/s: 1st                                                   2nd
Usual Residence - Property Name (if applicable):
Street No. and Name:
Suburb / Town:                                                            State                             Postcode
Sex:                          Male                   Female                    Unknown               Not determined

Marriage Particulars
   Never Married         Married       Separated (Not Divorced)          Divorced        Widowed       Defacto    Unknown   Tribal
                   Place of Marriage                     Date of Marriage              To Whom
1st Marriage                                                      /        /
2nd Marriage                                                      /        /
3rd Marriage                                                      /        /
4th Marriage                                                      /        /

Children of Deceased
Given Names                                              Date of Birth                 Age       Deceased                   Sex
                                                                  /        /
                                                                  /        /
                                                                  /        /
                                                                  /        /
                                                                  /        /
                                                                  /        /
                                                                  /        /

Parents’ Particulars
Surname of Father:                                                        Given names of Father:
Main occupation of Father:
Maiden surname of Mother:                                                 Given names of Mother:
Main occupation of Mother:

Doctors Name:                                                             Phone:
Surgery Address:
Funeral Service Information
The following information will help us to design your funeral service and carry out your wishes. This form can be filled out and emailed to
us or printed and kept with your personal documents for future reference.
Any person can officiate at a funeral service, if you do not have a specific minister of religion or funeral celebrant we can organise this for
you. You can also nominate a number of family, friends, business and club associates to speak during the service.
   Clergy - Religion:                             Name:                                                 Phone:
   Funeral Celebrant -                            Name:                                                 Phone:
   Family Member/Friend 1 -                       Name:                                                 Phone:
   Family Member/Friend 2 -                       Name:                                                 Phone:
   Business/Club Associate 1 -                    Name:                                                 Phone:
   Business/Club Associate 1 -                    Name:                                                 Phone:
Pallbearers usually act as a Guard of Honour alongside the hearse, carry the casket and lower the casket into the grave. Pallbearers can
assist with any or all of these duties. Our funeral attendants are happy to fulfil this role, however, a minimum of two pallbearers are
required for funerals outside the metropolitan area.
Name:                                                                   Phone:
Name:                                                                   Phone:
Name:                                                                   Phone:
Name:                                                                   Phone:
Name:                                                                   Phone:
Name:                                                                   Phone:
It is generally recognised that spending time with the deceased is beneficial for mourners, however, this decision is purely a personal one.
This can be done with an open casket/coffin or a closed casket. A viewing can be held at our funeral home, the family home or at your
Church, a casket can not be opened for a viewing once we have entered the Cemetery gates.
   Open Casket              Closed Casket          Funeral Home             Residence               Church                  Rosary
Funeral Service
The main portion of the funeral service can be held in either a Church, Funeral Home, Cemetery Chapel, park, beach, family home, garden or
country property. In fact, anywhere that is appropriate - if in a public area permission must be obtained from the necessary authorities.
Church Name:                                                            Phone:
Church Address:
   Funeral Home:        Willetton     Fremantle      Midland        North Perth       Wangara       Victoria Park
   Crematorium Chapel:
   Graveside Only:
   Other Place:
Final Disposition
   Cremation                Burial              Cemetery:
Deed of Grave to be issued to: (Burial Only)
Name:                                                                   Phone:
Re-Open Grave:
A grave that already has a family member interred, and you wish to use again. In most cemeteries a maximum of 3 interments are allowed.
The following information is required to correctly identify the grave. If you do not have all the information required please supply date of
last interment and the name of the person last interred in the grave.
App. No.                             Deed No.                           Grave No.
Sec.                                 Denom.
Date of Last Interment:                                                 Name of last interment:
Special Instructions
Listed below are a number of options that can be incorporated in the funeral service. If you have any other requests for personalising your
funeral service please list them under the Notes section.

Flag:                                                       Charity Donation Envelopes:
   Photo Board             Balloons                Butterflies              Doves                   Catering                 Bugler
   Piper                   Singer                  RSL                      Last Post               Poppies                  Rotary
   Masonic                 Accacia                 Video                    Orders of Service
   Webcasting (Karrakatta & Pinnaroo Cemeteries Only)                       Personal Memorabilia Display

Casket and Floral Selection
If you wish to view a selection of caskets and floral tributes please contact us using the details provided below.

                                              Mareena Purslowe & Associates              The Grief Recovery & Funeral
                                              368 Rokeby Road, Subiaco                   Education Centre
                                              Telephone: (08) 9388 1623                  368 Rokeby Road, Subiaco
                                              Facsimile: (08) 9388 1627                  Telephone: (08) 9388 1628
                                              8 Augusta Street, Willeton                 Facsimile: (08) 9388 1627
                                              Telephone: (08) 9457 0044                  Other Funeral Home Locations:
                                              Facsimile: (08) 9457 2608                  Fremantle, North Perth, Midland, Wangara, Victoria Park.

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