Death Certificate Details Family Members / Executors Details Name * First Name Last Name Relationship * Phone * (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Name * First Name Last Name Relationship * Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Death certificate details Name of Deceased * First Name Last Name Also known as Maiden Name * Date of Birth * MM DD YYYY Date of Death * MM DD YYYY Where did your loved one pass * Place of Birth * Type of service Burial Cremation Date of Final Disposition MM DD YYYY Place of Final Disposition Born in NZ * Yes No If not born in NZ, Year of arrival into NZ Gender Was the deceased a descendant of NZ Māori * Yes No Usual Occupation Ages of Children Daughters Sons Parent's Details Mother's Full Name (if known) First Name Last Name Mother's Maiden Name (if known) Father's Full Name (if known) First Name Last Name Marital Status at Date of Passing Married Never Married Partner of De Facto Widowed Civil Union Separated Marriage Dissolved If married, complete the following details Place of marriage Spouse's Full Name First Name Last Name Age (if living) Applicant's age at Marriage If previously married, complete the following details Place of marriage Spouse's full name First Name Last Name Age (if living) Applicant's age at marriage If previously married, complete the following details Place of marriage Spouse's full name First Name Last Name Age (if living) Applicants age at Marriage Thank you!
