Applicant Details

Applicant Full Name*: Applicant Address*: Applicant Email Address*: Applicant Contact Number*: Applicant Relationship with Deceased*:
Appropriate Person
Personal Representative
Another Adult

Service Details

Address For Service*:
Eco Memorial Park, 21 Quinns Hill Road West
Nudgee Crematorium, 493 St Vincents Rd, Nudgee

Deceased Person Details

Full Name of Deceased Person*: Usual or Last Known Address of Deceased Person: Date and Place of Death of Deceased Person: Deceased Gender*:

Age of Deceased Person:

Date of Birth of Deceased Person:

Usual Occupation*: Was the Deceased retired?*:

Place (Town) of Birth*:

If born overseas, what year did the deceased first arrive in Aus?:

Was the deceased Aboriginal or Torres Strait Islander origin:

Deceased Fathers First Names: Deceased Fathers Surname: Deceased Fathers Occupation:

Deceased Mothers First Names: Deceased Mothers Maiden Name: Deceased Mothers Occupation:

What was the relationship status of the deceased at the time of death:
Never Married
Registered Relationship
De facto

First Marriage – Full Name of Person: First Marriage – Maiden Name: Place of Marriage (Town/City): Age of Deceased at time of First Marriage:

Second Marriage – Full Name of Person: Second Marriage – Maiden Name: Place of Marriage (Town/City): Age of Deceased at time of Second Marriage:

Child 1 First Name(s):

Child 1 DOB:

Child 2 First Name(s):

Child 2 DOB:

Child 3 First Name(s):

Child 3 DOB:

Child 4 First Name(s):

Child 4 DOB:

Death Registration

Address where Death Certificate to be posted to

Form 1 Details

1. Person Issuing Medical Cause of Death Certificate*:
Independent Doctor

2. Signed Instructions*:
The Deceased left signed or verbal instructions that their human remains to be cremated
I dont know if the Deceased left instructions

3. Objections to the cremation of the deceased person*:
I am not aware of any objections from the following people (spouse, adult child, parent or personal representative)
There is an Objection

4. Cremation Risk*:
The deceased person’s human remains contain a cremation risk (eg. Pacemaker)
Remains do not contain a Risk
I do not know if the Remains contain a Risk
If Remains do contain a Risk, please specify*:

Pricing Details

Total $:

Credit Card Number (Visa/MC) 16 digits No Spaces No Dashes:

Expiry Date (MM/YY):


Agreement to Release Deceased Body

Place of passing (Hospital Name or Name of Aged Care Facility)*:

Instructions for Dealing With Ashes

Instructions for Ashes*:
Collected by, Delivered to Cremations Only
Delivered to Address Below
Remain at Crematorium
Scattered within Crematorium grounds
To be collected by person below