Application for Interment Authorisation Form

Agreement Number *

This will be given to you by your funeral consultant

Deceased Details

Name *

First

Last

Gender *

Age *

Date Of Birth *//

Date Of Death *//

Usual Residence

Name of place / institution

Street no. and name *

Suburb / Town *

State *

Postcode *

Did the deceased have a spouse or domestic partner at the time of the deceased's death? *

Applicant Details

Title *

Name *

First

Last

Street no. and name *

Suburb / Town *

State *

Postcode *

Phone Number

Mobile Number *

Email *

Email

Confirm Email

Applicant Signature *

Are you the holder of the right of interment for the place of interment where the remains will be interred? *

Title *

Name *

First

Last

Street no. and name *

Suburb / Town *

State *

Postcode *

Phone Number

Mobile Number *

Email *

Email

Confirm Email

Signature

Has the holder of the right of interment been informed of this application? *

Please give reasons why the holder of the right of interment has not been informed of this application: *

Does the holder of the right of interment consent to this application? *

1800 012 011

03 9480 1061

Deceased Details

Usual Residence

Applicant Details