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Information Form

The Death Registration Statement is an interactive form (see below) which must be completed to enable Simple Goodbyes to register a death with Births, Deaths and Marriages ACT. Once the registration process is completed the information is NOT retained by Simple Goodbyes.

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DETAILS OF THE DECEASED

Surname/Family Name

Given Name/s (including middle name)

Surname/Family Name at Birth

Given Names at Birth

Any other Surnames/Family Names Used

Any other Given Names Used

Date of Birth

Deceased-Date of Death

Sex

Occupation/profession (prior to retirement)

Place of Birth (town/city and state/country)

Place of Death

Last Home address

Postcode

Was the deceased born outside australia
NoYes

If so period of time in Australia -Yes

Was the death reported to the Coroner
NoYes

Was the deceased of Aboriginal or Torres Strait Islander origin
NoYes, Aboriginal originYes, Torres Strait Islander originYes, both Aboriginal and Torres Strait Islander origin

RELATIONSHIP DETAILS OF DECEASED AT TIME OF DEATH

Was the deceased in a relationship at time of death
NOYes (If yes please indicate type below)

Domestic partnershipCivil PartnershipMarriedDivorcedWidowed

Full name (including middle name) of partner/spouse at commencement of relationship

Place of Marriage/Partnership (If Applicable)

Date of Marriage/Partnership

DETAILS OF ANY OTHER RELATIONSHIPS OF DECEASED

Any domestic partnerships the deceased had been in at anytime including the date and place of marriage/partnership

Full name (including middle name) of partner/spouse at commencement of relationship

Place of Marriage/Partnership (If Applicable)

Date of Marriage/Partnership

Full name (including middle name) of partner/spouse at commencement of relationship

Place of Marriage/Partnership (If Applicable)

Date of Marriage/Partnership

Full name (including middle name) of partner/spouse at commencement of relationship

Place of Marriage/Partnership (If Applicable)

Date of Marriage/Partnership

Full name (including middle name) of partner/spouse at commencement of relationship

Place of Marriage/Partnership (If Applicable)

Date of Marriage/Partnership

CHILDEREN OF THE DECEASED (Please enter in order of birth)

Given names in full (including middle name)

Date of Birth

Gender

Is this child deceased ?
NOYES

Given names in full (including middle name)

Date of Birth

Gender

Is this child deceased ?
NOYES

Given names in full (including middle name)

Date of Birth

Gender

Is this child deceased ?
NOYES

Given names in full (including middle name)

Date of Birth

Gender

Is this child deceased ?
NOYES

Given names in full (including middle name)

Date of Birth

Gender

Is this child deceased ?
NOYES

Given names in full (including middle name)

Date of Birth

Gender

Is this child deceased ?
NOYES

Given names in full (including middle name)

Date of Birth

Gender

Is this child deceased ?
NOYES

DETAILS OF DECEASED'S BIRTH MOTHER

Surname

Given Names

Former/maiden name

Occupation (prior to retirement)

DETAILS OF DECEASED'S BIRTH FATHER

Surname

Given Names

Former name

Occupation (prior to retirement)

DETAILS OF THE RESPONSIBLE PERSON

Surname

Given name/s (including middle name)

Address

Postcode

Daytime telephone number

Relationship to deceased

Email address

Occupation

Funeral directors businesscompany name and phone numberRow1

Full name of funeral director or person responsible for disposalRow1

Address of the funeral company

If celebrant is a minister of religion specify the denomination or if celebrant is a Civil Celebrant specify

Full name of celebrant if present at burial or cremation

Place of disposal of remainsRow1

Full name of person who witnessed disposal of remainsRow1

Date of disposal-Deceased

Burial
Burial

Cremation
Cremation

In custody of educational/scientific institution
In custody of educational/scientific institution

Removal from ACT
Removal from ACT

Surname of funeral director or person responsible for removalRow1

Address of funeral director or person responsible for removalRow1

Given name of funeral director or person responsible for removalRow1

Occupation of person responsible for removalRow1

Purpose of removal and if for anatomical examination name of the institution where this is to take place

Surname of person having custody of the remainsRow1

Given Names of the person having custody of the remainsRow1

Address of person having custody of the remainsRow1

Occupation of the person having custody of the remainsRow1

Date of removal _af_date

Reason Certificate is RequiredRow1

Postal Address If different from residential addressRow1

Cremation Date

Funeral Director

Deceased Marital Status

Please provide details_3

Time of Death

Hour of Death

Details of battery powered

any relatives object cremation provide details

I have verified that the remains submitted for cremation are those of the above mentioned
I have verified that the remains submitted for cremation are those of the above mentioned

I have provided the application for cremation
I have provided the application for cremation

I have provided the medical certificate cause of death
I have provided the medical certificate cause of death

I have provided the certificate of medical referee
I have provided the certificate of medical referee

If foetal remains, a signed statement by nurse
If foetal remains, a signed statement by nurse

Battery powered removed- Yes
Battery powered removed- Yes

Battery Powered removed - NO
Battery Powered removed - NO

Does the deceased have battery powered - Yes
Does the deceased have battery powered - Yes

Does the deceased have battery powered- NO
Does the deceased have battery powered- NO

Objected proposed cremation- yes
Objected proposed cremation- yes

Objected proposed cremation- NO
Objected proposed cremation- NO

Informed creation- Yes
Informed creation- Yes

Information creamation- No
Information creamation- No

Mode of disposal of remains- yes
Mode of disposal of remains- yes

Mode of disposal of remains- NO
Mode of disposal of remains- NO

I am aware that the deceased may not be cremated on the day of service
I am aware that the deceased may not be cremated on the day of service

I am the nearest living relative
I am the nearest living relative

I am not nearest living relative
I am not nearest living relative

Please provide details- Not nearest relative

Please provide details_2- Deceased mode of disposal of remains

Cremation details -Service
Cremation details -Service

Cremation details -Direct
Cremation details -Direct

Given names in fullRow8

children8-sex

Childern-Deceased-row8_af_date

Childeren 8- NO
Childeren 8- NOChilderen 8- YES

Given names in fullRow9

children9-sex

Childern-Deceased-row9_af_date

Childeren 9- NO
Childeren 9- NOChilderen 9- YES

Peter Dinn and Mark Copley for over 30 years of combined experience, offering quality funeral services at fair and reasonable prices.

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