Bare Cremation - VIC Forms

1
Let's start with your Full name* This field is required.
Title
First Name
Middle Name
Last Name
2
Your Best Contact Phone Number* This field is required.
3
Your best contact Email* This field is required.
example@example.com
4
Your Address* This field is required.
Street Address
Street Address Line 2
Suburb
State
Postcode
Australia
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
5
Is this the same as your Postal Address?* This field is required.
YESNO
6
Your Postal Address* This field is required.
Street Address
Street Address Line 2
Suburb
State
Postcode
Australia
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
7
Your Date of Birth* This field is required.
Date
Day
Month
Year
8
Relationship to deceased* This field is required.
9
Please provide a secondary contact name* This field is required.We will only contact this person as a last resort if we have been unable to get in touch with you for a period of time
First Name
Last Name
10
Secondary contact phone number* This field is required.
11
Deceased Name* This field is required.
Title
First name
Middle Name
Surname
12
Deceased Name* This field is required.
Title
First name
Middle Name
Surname
13
Was this their surname at Birth?* This field is required.
YESNO
14
Please enter family name at Birth* This field is required.
15
Sex of Deceased* This field is required.
Male
Female
16
Sex of Deceased* This field is required.
Male
Female
17
Date of birth of deceased (if known)* This field is required.
Date
Day
Month
Year
18
Place of Birth* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Australia
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
19
If born overseas, in what year did the deceased first arrive in Australia?* This field is required.This section cannot be blank - if you are unsure, please enter your best estimate
20
Deceased Residential Address at the time of passingMust be a street address, not a PO Box
Street Address
Street Address Line 2
Suburb
State
Postcode
Australia
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
21
Date of death
Date
Day
Month
Year
22
Age (in years)
Age of the deceased at time of death
23
Does the Deceased Have a Pacemaker or Battery Operated Medical Device?
Yes
No
24
Your Signature Confirmation - Application for Cremation Authorisation* This field is required.By signing the below, I certify that the information on this form is correct for the purpose of completing Form 3 - Application for Cremation Authorisation. Please note it is important that you advise the cemetery trust of any changes to your contact details as the cemetery trust will use these details to contact you about the cremated remains in the future.
Clear
25
Signature Date* This field is required.
Date
Day
Month
Year
26
Signature Date* This field is required.
Date
Day
Month
Year
27
Where did the deceased pass away?
Hospital
Nursing Home
Private Residence
Other
28
What is the name of the hospital the deceased passed away?
29
What is the name of the nursing home the deceased passed away?
30
What was the full address of the place of deathFull address of home, hospital, nursing home etc.
Street Address
Street Address Line 2
Suburb
State
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
31
Usual occupation of deceased during working life* This field is required.
32
Was the deceased retired?* This field is required.
Yes
No
33
Was the deceased a pensioner?* This field is required.
Yes
No
34
Religion* This field is required.Type N/A if not applicable
35
Was the deceased of Aboriginal or Torres Strait Islander origin?** This field is required.
No
Yes (Aboriginal)
Yes (Torres Strait Islander)
Yes (Aboriginal and Torres Strait Islander)
36
What was the relationship status of the deceased at the time of death?
Never married
Married
Divorced
Widowed
Registered relationship
De facto
Unknown
37
Partners Name
38
When did this defacto relationship start?
Date
Day
Month
Year
39
Marriages or registered relationships of the deceasedList all marriages or registered relationships of the deceased starting with the earliest. Please indicate whether a Marriage (M) or a registered relationship (R)
Given Names
Middle Names
Surname
Gender (M or F)
Event Date
Event Town/Suburb
Event State
Country
Marriage (M) or Registered Relationship (R)
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Event Date
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Event Town/Suburb
Row 0, Column 5
Event State
Row 0, Column 6
Country
Row 0, Column 7
Marriage (M) or Registered Relationship (R)
Row 0, Column 8
Given Names
Row 1, Column 0
Middle Names
Row 1, Column 1
Surname
Row 1, Column 2
Gender (M or F)
Row 1, Column 3
Event Date
Row 1, Column 4
Event Town/Suburb
Row 1, Column 5
Event State
Row 1, Column 6
Country
Row 1, Column 7
Marriage (M) or Registered Relationship (R)
Row 1, Column 8
Given Names
Row 2, Column 0
Middle Names
Row 2, Column 1
Surname
Row 2, Column 2
Gender (M or F)
Row 2, Column 3
Event Date
Row 2, Column 4
Event Town/Suburb
Row 2, Column 5
Event State
Row 2, Column 6
Country
Row 2, Column 7
Marriage (M) or Registered Relationship (R)
Row 2, Column 8
Given Names
Row 3, Column 0
Middle Names
Row 3, Column 1
Surname
Row 3, Column 2
Gender (M or F)
Row 3, Column 3
Event Date
Row 3, Column 4
Event Town/Suburb
Row 3, Column 5
Event State
Row 3, Column 6
Country
Row 3, Column 7
Marriage (M) or Registered Relationship (R)
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Parents of the deceased detailsNote: Retired/Retiree/Pensioner is not classified as an occupation. Please enter the occupation for the majority of the person's life. Write N/A for any cells not applicable.
First Name
Middle Names
Surname
Surname at birth
Occupation
Date of Birth
Father
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Mother
Row 1, Column 0
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Row 1, Column 5
Father
Mother
First Name
Row 0, Column 0
Middle Names
Row 0, Column 1
Surname
Row 0, Column 2
Surname at birth
Row 0, Column 3
Occupation
Row 0, Column 4
Date of Birth
Row 0, Column 5
First Name
Row 1, Column 0
Middle Names
Row 1, Column 1
Surname
Row 1, Column 2
Surname at birth
Row 1, Column 3
Occupation
Row 1, Column 4
Date of Birth
Row 1, Column 5
1 of 2
41
Has the deceased ever had any children?* This field is required.Biological or Adopted Children only.
YESNO
42
List the first names of all the deceased’s childrenList names in order of their birth (from oldest to youngest). If the child is deceased enter ‘D’ in age column. If not born alive enter ‘SB’ in age column. If more than ten children, please email service@bare.com.au with their details. Include legally adopted children. If no children write ‘None’. Please include child's family name at BIRTH.
Given Names
Middle Names
Surname
Family Name At Birth
Date of Birth
Age
1.
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4.
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5.
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6
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8
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Given Names
Row 0, Column 0
Middle Names
Row 0, Column 1
Surname
Row 0, Column 2
Family Name At Birth
Row 0, Column 3
Date of Birth
Row 0, Column 4
Age
Row 0, Column 5
Given Names
Row 1, Column 0
Middle Names
Row 1, Column 1
Surname
Row 1, Column 2
Family Name At Birth
Row 1, Column 3
Date of Birth
Row 1, Column 4
Age
Row 1, Column 5
Given Names
Row 2, Column 0
Middle Names
Row 2, Column 1
Surname
Row 2, Column 2
Family Name At Birth
Row 2, Column 3
Date of Birth
Row 2, Column 4
Age
Row 2, Column 5
Given Names
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Middle Names
Row 3, Column 1
Surname
Row 3, Column 2
Family Name At Birth
Row 3, Column 3
Date of Birth
Row 3, Column 4
Age
Row 3, Column 5
Given Names
Row 4, Column 0
Middle Names
Row 4, Column 1
Surname
Row 4, Column 2
Family Name At Birth
Row 4, Column 3
Date of Birth
Row 4, Column 4
Age
Row 4, Column 5
Given Names
Row 5, Column 0
Middle Names
Row 5, Column 1
Surname
Row 5, Column 2
Family Name At Birth
Row 5, Column 3
Date of Birth
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Age
Row 5, Column 5
Given Names
Row 6, Column 0
Middle Names
Row 6, Column 1
Surname
Row 6, Column 2
Family Name At Birth
Row 6, Column 3
Date of Birth
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Age
Row 6, Column 5
Given Names
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Middle Names
Row 7, Column 1
Surname
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Family Name At Birth
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Date of Birth
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Age
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Given Names
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Middle Names
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Surname
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Family Name At Birth
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Date of Birth
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Age
Row 8, Column 5
Given Names
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Middle Names
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Surname
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Family Name At Birth
Row 9, Column 3
Date of Birth
Row 9, Column 4
Age
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43
List the first names of all the deceased’s siblings* This field is required.List names in order of their birth (from oldest to youngest). If the sibling is deceased enter ‘D’ in age column. If not born alive enter ‘SB’ in age column. If more than five siblings, please email hello@barecremation.com.au with their details. If no siblings write ‘None’.
Given Names
Family Name
Date of Birth
Age
Place of Birth (Suburb, State, Country)
1.
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2.
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3.
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Given Names
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Family Name
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Date of Birth
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Age
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Place of Birth (Suburb, State, Country)
Row 0, Column 4
Given Names
Row 1, Column 0
Family Name
Row 1, Column 1
Date of Birth
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Age
Row 1, Column 3
Place of Birth (Suburb, State, Country)
Row 1, Column 4
Given Names
Row 2, Column 0
Family Name
Row 2, Column 1
Date of Birth
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Age
Row 2, Column 3
Place of Birth (Suburb, State, Country)
Row 2, Column 4
Given Names
Row 3, Column 0
Family Name
Row 3, Column 1
Date of Birth
Row 3, Column 2
Age
Row 3, Column 3
Place of Birth (Suburb, State, Country)
Row 3, Column 4
Given Names
Row 4, Column 0
Family Name
Row 4, Column 1
Date of Birth
Row 4, Column 2
Age
Row 4, Column 3
Place of Birth (Suburb, State, Country)
Row 4, Column 4
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44
Your Signature Confirmation* This field is required.By signing the below, I certify that the information on this form is correct for the purpose of registering the death with Births, Deaths and Marriages.
Clear
45
Today's Date* This field is required.
Date
Day
Month
Year
46
Where would you like the cremation to take place?At Bare we use both the Geelong and Ballarat Crematoriums. If you would like to choose which crematorium we use for your loved one please indicate below. If you do not have a preference we will still advise you of where the cremation will take place
Geelong Crematorium
Ballarat Crematorium
I do not have a preference
47
Crematorium (Text conversion)
48
How would you like the ashes returned?Please note that our hand delivery service is only available within Melbourne and its suburbs. All other regions in Victoria will be sent via Australia Post Express with signature. If collecting from the crematorium, it will be the same crematorium (Geelong or Ballarat) where the cremation takes place. Please note that you have 12 months to collect the ashes, after which time they can dispose of the ashes in an appropriate manner.
Hand Delivery (Melbourne and its Suburbs)
Australia Post with Signature
I will collect from the crematorium
Someone else will collect from the crematorium on my behalf
49
Please confirm your full name for collection* This field is required.
50
As part of coordinating delivery back to you please confirm Bare Cremation can collect on your behalf by clicking Next.* This field is required.
51
Bare Agent
52
Bare Street
53
Bare Suburb
54
Bare State
55
Bare Post Code
56
Bare Phone
57
Bare Email
58
What is the full name of the person that will be collecting on your behalf?
Title
First Name
Last Name
59
What is the address of the person who will be collecting the ashes?
Street Address
Street Address Line 2
Suburb
Please Select
Please Select
ACT
NSW
NT
QLD
TAS
VIC
WA
State
Postcode
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
60
What is the phone number of the person who will be collecting?
61
Return of Ashes ConfirmationI have selected Australia Post with Signature as my method of ashes return. I confirm that Australia Post is responsible for the delivery of these ashes and I do not hold Bare Cremation accountable once the parcel has been registered with Australia Post.
Clear
62
Who will be responsible for paying for this service?* This field is required.
Myself
Someone Else
The Deceased Estate
Bare Prepaid
63
Please provide the name of the person responsible for paying* This field is required.If payment will come from the deceased estate, please provide the executor name.
64
Please provide the phone number of the person responsible for paying* This field is required.If payment will come from the deceased estate, please provide the executor phone number.
65
Please provide the email address of the person responsible for paying
example@example.com
66
Do you plan on having a memorial service for your loved one in the future?* This field is required.
Yes
No
Undecided
67
Would you like for us to arrange a celebrant to assist?* This field is required.There is an additional fee for this, however you are not committing to anything by answering Yes. This is just so we know that you would like to discuss the options with us. Our celebrant will: * Meet with you to talk through your needs * Put together a service for you * Present the service for you on the day
No, I'd like to arrange a service myself
Yes, I would like Bare to discuss options with me
68
How did you hear about Bare?
Healthcare Worker Referral
Resources given by facility where death occurred
Previous Bare customer referral
Family/friend
Deceased prepaid/will
Online search
TV
Facebook
Other
69
Would you like Bare to speak with you about our options?* This field is required.
YESNO
70
Would you like us to notify Centrelink of the death?* This field is required.
Yes
No
71
You have now completed all forms required. Please select "Review" and check all answers prior to submitting.

Once submitted, the forms will be sent directly to your arranger.
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