Death Registration Statement – Whitehaven Funerals

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DEATH REGISTRATION STATEMENT | Please provide us with the following information which is required by Births Deaths and Marriages when lodging for your loved one’s official Death Certificate. Please remember that official death certificate may take between 4-6 weeks to be posted to the informants.

Name of deceased (required): *

Eg. John William Smith

Date of death (required): *

Eg. 01/02/1934

Date of birth (required): *

Eg. 01/02/1934

Sex of deceased (required): *

Male
Female
Indeterminate
Unknown

Place of death including institution name if applicable (required): *

Eg. St Vincents Hospital - 41 Victoria Parade, Fitzroy VIC 3065

Usual occupation during working life (required): *

Eg. Home Duties, Self Employed, Hospitality Worker

Was the deceased born in Australia (required): *

Yes
No

Specify place of birth, including Country if not Australia (required): *

Eg. Melbourne, Australia

How long did the deceased live in Australia (required): *

Eg. 50 years (or Since Birth)

Usual residential address (required): *

Eg. 1 Collins Street, Melbourne

Was The deceased of Aboriginal or Torres Strait Island origin (required): *

No
Aboriginal
Torres Strait Island
Both

Was the deceased either married or in a domestic relationship at the time of death? *

Yes, Married
Yes, Domestic Relationship
No, Divorced
No, Single
No, Widowed
No, Never Validly Married/Single
Unknown

If the deceased was married and never legally divorced, you must select "Yes, Married" for this question.

If the deceased is female and married, what was her maiden name prior to marriage?

Eg. Smith

First marriage - Given name of spouse:

Eg. Rita

First marriage - Surname of spouse:

If spouse is a female, this could be her maiden name or her previous married name. Eg. Wilson

First marriage - Place of marriage:

Eg. Melbourne, Australia

First marriage - Date of marriage:

Eg. 02/03/1964

Second marriage - Given name of spouse:

Eg. Rita

Second marriage - Surname of spouse:

If spouse is a female, this could be her maiden name or her previous married name. Eg. Wilson

Second marriage - Place of marriage:

Eg. Melbourne, Australia

Second marriage - Date of marriage

Eg. 02/03/1964

Third marriage - Given name of spouse:

Eg. Rita

Third marriage - Surname of spouse:

If spouse is a female, this could be her maiden name or her previous married name. Eg. Wilson

Third marriage - Place of marriage:

Eg. Melbourne, Australia

Third marriage - Date of marriage

Eg. 02/03/1964

Was the deceased ever in a domestic relationship registered with the Victorian Registry of Births, Deaths and Marriages (required): *

Yes
No

Did the deceased have any children (required): *

Children's given names:

Eg. John Smith 2/3/1964, Rita Citizen (Maiden: Jones) 20/4/1968, George Smith DEC

Deceased's mother's details - Mother's surname/family name (required): *