FORMS Death Certificate Form Family members / Executor's details Name 1 * First Name Last Name Relationship * Phone * Email Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Name 2 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 Place of death * Place of birth * Type of service * Burial Cremation Date of final disposition * MM DD YYYY Place of final disposition * Born in New Zealand * Yes No If not born in New Zealand, year of arrival into New Zealand Gender Male Female Neutral Was the deceased a descendant of NZ Māori? * Yes No Usual occupation * Ages of children Daughters * Sons * Parents' 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 Relationship status * Married Widower Widow Partner de Facto Civil Union Never Married 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 Applicant's age at marriage Age (if living) If previously married, complete the following details Place of marriage Spouse's full name First Name Last Name Applicant's age at marriage Age (if living) Date signed MM DD YYYY Thank you!
