Pre-Arrangement Form
Take your time with these questions —there’s no need to rush, especially if the death is recent. A cup of tea in hand can help, and if anything feels overwhelming, just give us a call. We can go through the form with you, step by step. The information helps us prepare legal documents like the Death Certificate and lets us understand your wishes if we haven’t spoken yet. If you don’t know an answer, it’s okay to write 'unknown'. Double-check names, addresses, and other details so everything is correct for official records. Once you’ve finished, press Submit and we’ll be in touch to confirm we’ve received it. If you need any help along the way, call us on 0406 103 699—we’re here for you.
Authority to Transfer
Please fill in your details as the applicant, this first part needs to be done by the senior next of kin, executor or person acting on behalf of the senior next of kin or executor. If you are unsure about this please call us to discuss. This authorisation request allows us to bring your person into our care from place of death.
Name
*
First & Middle Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: 0000-000-000.
You are the, mark all relevant
*
Next of Kin
Executor
Applicant
Other
Who is the Executor
*
Who will be receiving the Death Certificate? Please state name and address, if the same as above please write as above.
Relationship to who has passed?
*
Date of Birth
*
-
Day
-
Month
Year
Date
Current Age
*
Date Signed
*
-
Day
-
Month
Year
Date
By signing this document you: (please tick all)
*
declare that the information is true & correct & to the best of my knowledge. I understand that Undertaking Grace Deathcare & Funerals is relying on my representations about my authority to act & the wishes of the family in carrying out these arrangements.
confirm that, to the best of my knowledge, there is no other person with an equal or greater legal right to arrange the funeral who objects to these arrangements.
authorise Undertaking Grace Deathcare & Funerals, its staff & nominated contractors to transfer from the place of death and /or any current place of care (for example home/hospital/aged care facility/coronial facility or other mortuary) & transfer to the mortuary used by Undertaking Grace Deathcare & Funerals & any other facilities reasonably required to carry out the agreed funeral arrangements then deliver them to the place of ceremony, burial, cremation & any other agreed location.
understand that Undertaking Grace may engage trusted transfer providers or mortuaries on our behalf and that they are required to follow all relevant health, safety & public health regulations.
*
The following questions will help us gather all the personal information of your loved one who has passed.
Family name
*
Family name at birth/maiden name
*
First given name
*
Middle/other given names
Preferred name
Sex
*
Male
Female
Intersex
Indeterminate
Non specific
Age at date of death
*
Date of birth
*
-
Day
-
Month
Year
Date
Date of death/if not yet passed please do date of birth again
*
-
Day
-
Month
Year
Date
Cause of death. If death has not yet occurred, please let us know the current situation. If cause of death is 'coronial', please write coronial.
*
Location of death
*
At Home
Hospital
Aged Care Facility
Hospice
Other - Coronial
Place of death - address of where death occurred or where you may anticipate the death to occur
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Usual Residential Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Place of birth - town, state & country
*
Retired at date of death?
*
Yes
No
If on a pension, please indicate which type or N/A
*
If born outside Australia, what year did they arrive in Australia?
Occupation in working life
*
Aboriginal or Torres Strait Islander origin
*
Aboriginal
Torres Strait Islander
Both Aboriginal & Torres Strait Islander
Neither
Unknown
Marital status at time of death
*
Married
Widowed
Seperated
De facto
Never married
Unknown
Please record current & all previous marriage or de facto relationships: Place of marriage, age when married or when de facto relationship began, Country - Suburb, Town,City - Spouse Family Name, Spous Given Name, Spouse Gender
*
Number of children (do not include step children, only note birth children & legally adopted children)
*
Children's details - from Eldest to Youngest - First Given Name - Middle Name - Status (alive, deceased or unknown) - Gender (male, female, intersex, indeterminate, non-specific) - Date of Birth.
*
Parent 1 (Mother of the person who has passed)
*
First Name
Last Name
Parent 1 maiden name (Mother of the person who has passed)
*
Parent 1 Sex
*
Male
Female
Intersex
Indeterminate
Non specific
Parent 1 Life Status
*
Alive
Deceased
Unknown
Parent 1 Occupation
*
Parent 2 (parent of the person who has passed)
*
First Name
Last Name
Parent 2 Sex
*
Male
Female
Intersex
Indeterminate
Non specific
Parent 2 Life Status
*
Alive
Deceased
Unknown
Parent 2 Occupation
*
Usual doctor, address & phone number or last visited doctor or medical centre
*
Does the deceased have a pacemaker or defibrillator fitted?
*
Yes
No
Unsure
Has the deceased received any radiopharmaceuticals or radioactive compounds for therapeutic purposes in the last 12 months?
*
Yes
No
Unsure
Height & Weight (we require height & weight for transfers & coffin sizing)
*
Consent to Care & Preparation of the Body
*
I authorise Undertaking Grace Deathcare & Funerals, in keeping with our agreed wishes & in alignment with Qld public health requirements, to provide gentle care & preparation including as appropriate: respectful washing, cooling & care of the body, closing of mouth & eyes naturally with no invasive procedures, shaving & haircare where needed, dressing and/or shrouding according to our instructions ensuring all cultural & spiritual practices are respected.
I consent to carrying out minor & restorative care that may be needed for safe & comforting viewing.
I understand that any invasive procedures such as embalming or reconstruction will not be carried out without my further specific consent, unless required by law or coroner.
I consent to placing them in a coffin, shroud bearer, Paperbark Pod or other chosen vessel.
Undertaking Grace sometimes needs to take limited, clinical photographs. This may be to: identify/document condition on arrival or before/after care to meet health, safety or regulatory requirements, provide evidence for coronial, legal or insurance processes (if relevant). These images are not used for marketing, social media or public sharing. they are stored securely in Undertaking Grace's records & only shared where reasonably necessary (for example with the coroner, a regulator, insurer, or another care provider), or where required by law.
*
I DO consent to Undertaking Grace Deathcare & Funerals taking & securely storing photographs for the practical purposes described above (identification, documentation & required records).
I DO NOT consent to photographs being taken except where required by Law or by a coroner/authorised authority.
Where I have requested photographs as a memory keepsake, I understand these will only be shared directly with me/us or our nominated person and Undertaking Grace will not use them for any other purposes without our separate written consent.
Privacy: I understand that Undertaking Grace will handle all information and images in line with Australian privacy law. Records are kept securely for the period required by law and then destroyed or archived in accordance with regulatory requirements
Is there a prepaid or funeral bond in place? Please provide contact details
Will any other family members or other parties be contributing to paying the invoice? Please provide their name, email address & phone number
*
What service would you like? You may request more than one
*
Undertaking Grace Direct No Attendance Cremation
Undertaking Grace Direct No Attendance Cremation with viewing
Undertaking Grace Cremation with small initimate Ceremony
Undertaking Grace Cremation with Ceremony/Funeral/Memorial/
Undertaking Grace Direct Burial
Undertaking Grace Direct Burial with viewing
Undertaking Grace Burial with small intimate Ceremony
Undertaking Grace Burial with Ceremony/Funeral/Memorial
Home Vigil - POA
Ceremonialist only
Unsure - would like to discuss
Are there any other additional requests for deathcare & funeral arrangements?
What sort of coffin/casket/shroud would you prefer?
*
Bioboard coffin - this is what is used for all Direct No Attendance Cremation
Wicker Handwoven
Natural Eco Wooden/Pine
Traditional Style
Paperbark Pod - shroud on bearer wrapped in paperbark
Unsure - would like to discuss
Any other additional information you would like us to know?
How did you find out about Undertaking Grace? (for example - friend or family, healthcare referral, Google search)
*
By signing this form you are entering into a service agreement with Undertaking Grace Deathcare & Funerals to carry out the burial or cremation & any associated ceremony as discussed. This agreement gives us permission to make any necessary arrangements on your behalf, including coordinating with external service providers. Please note that invoices are due upon receipt, as we are required to pay our suppliers such as - crematoria, cemeteries, florists & other vendors at the time of service. In some cases a 50% deposit may be required before certain arrangements can proceed. We appreciate your understanding & timely attention to these matters.
*
Agree
Next steps
Contact me to set up an appointment or telephone conversation
Send me a quote for services
No appointnment necessary, I am getting organised & would like you to keep these details on file
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