Cemetery Service Request Form - Rockhampton Regional Council

Cemetery Service Request Form
Privacy Notice: Rockhampton Regional Council is collecting the personal information you supply on this form for the purpose of processing your
application. Your personal details will not be disclosed to any other person or agency external to Council without your consent unless required or
authorised by law.
This form is to be completed when a Funeral Director wishes to arrange a burial service, or when an individual wishes to organise ashes,
chapel or garden services at one of Rockhampton’s cemetery locations. Applications must be submitted no less than two business days
prior to the required date and time of the service. Contact Cemeteries on 4936 8374 or via [email protected] for further
information.
Applicant Details
Contact name:
Postal address:
Preferred contact number:
Email:
Right of Burial Holder Details (if not applicant) (please note a Right of Burial Holder is the lawful holder of the burial right. A burial right
is the exclusive rights to a burial site, which is granted by Council)
□ Same as applicant (details above)
Contact name:
Postal address:
Preferred contact number:
Email:
Relationship to deceased person:
Proof of ID (please supply proof of ID for the Right of Burial Holder. a photocopy must be provided at the time of lodgement)
ID number:
ID type:
Expiry date:
Declaration (to be completed by the Right of Burial Holder or the applicant if permission from the Right of Burial Holder has been received. For
existing or reserved sites only)
I
declare that I am the legitimate holder of the Right of Burial for the site recorded on
this form, or I have obtained and attached permission from the legitimate Right of Burial Holder to use the grave in question.
Name:
Signature:
Date:
Witness:
Signature:
Date:
Funeral Director Details (please leave this section blank if not applicable)
Organisation name:
Contact name:
Postal address:
Preferred contact number:
Email:
Funeral Director Declaration
As funeral director, I have fulfilled all statutory requirements to allow burial of the deceased.
Name:
Signature:
Date:
Deceased Person Details
Full name:
Date of death:
Gender:
OFFICE USE
ONLY
Age:
□ Male
□ Female
Religion:
Register number:
A/C reference:
File 562 – zztCemeteries – QDAN 480 v.4 – 24.2.1 - Permanent
PAR02 | V1 | Approved 6 May 2016
Page 1 of 2
Service Details (please leave the ‘Section’, ‘Row’ and ‘Grave no’ fields blank if you are unsure of these details)
□ New plot/niche
□ Pre-purchase of plot/niche
□ Re-open plot/niche (complete details below)
Name of last interment:
Type:
Location:
Date:
□ Ashes
□ Burial
□ Chapel
□ Other (please specify):
□ Memorial Gardens
□ North Rockhampton Cemetery
□ Mount Morgan Cemetery
□ Gracemere Cemetery □ Bajool Cemetery
□ Other (please specify):
Section:
Grave number:
Row:
Day/date:
□ am / □ pm
Time of arrival:
□ am / □ pm
Time of service:
Approximate duration of service:
Setup Details (applicable to all services – contact Cemeteries Administration Office for assistance if required)
□ Yes
Is a standard set up required?
□
No
If no, please provide details of the preferred setup:
Interment Details (only applicable to burial and ashes services)
Is a graveside service required?
□ Yes
□
No (please specify):
Assistance Details (only applicable to burial and ashes services)
□ Yes
Is assistance required?
□
No
If yes, please provide details of the assistance required: (eg carry on)
Coffin Details
Is the coffin of standard or non-standard size?
Length:
□ Standard
□ Non-standard (provide dimensions below)
Width:
Height:
Refreshments (only applicable to chapel services)
Are refreshments required at the service?
□ Yes
□
No
Special Requests
Supporting Documentation
Please remember to provide the following supporting documentation when submitting this form:
□ Evidence of permission received from the Right of Burial Holder to use the grave in question.
Fees and Charges
Issue the invoice to:
□ Applicant
□ Burial Rights Holder
□ Funeral Director
For a full list of fees and charges please refer to Council’s Fees and Charges Schedule.
Payment Information
In person | You can pay at Council’s Customer Service Centres: 232 Bolsover Street, Rockhampton; 32 Hall Street, Mount
Morgan; 1 Ranger Street, Gracemere or at the Memorial Gardens, 21 Hartington Street, North Rockhampton.
By phone | Contact Customer Service on 4932 9000 to make payment via credit card or debit.
File 562 – zztCemeteries – QDAN 480 v.4 – 24.2.1 - Permanent
PAR02 | V1 | Approved 6 May 2016
Page 2 of 2
Submit