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 Surname: 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 Country 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: Certificates 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. Officiating 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 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: Viewing/Visitation 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 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: Address: 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 Notes: 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.