Personal Profile Record

Feel free to fill in the below form and if you wish, print out this form by clicking on print at the bottom of the page.

Family name:

First name(s)

Name at Birth ( if different from above )

Date of Birth:

No of years in NZ:

Place of Birth:

Street Address:

City:

Phone

Email:

Usual Occupation ( before retirement )

Ethnic Group

Maori Descent

Civil Honours ( eg. J.P. OBE etc

Full Name:

Street Address:

City:

Family infomation required by Registrar of Births, Deaths & Marriages

Sons name(s):

Date of Birth(s)

Daughters name(s):

Date of Birth(s)

Father name:

Mothers name:

Father birth name ( if different )

Mothers Maiden name:

Occupation:

Occupation:

Married

Never Married

Widowed

Permanently Seperated

Marriage Dissolved

Partnered or Defacto*

* Presently the law does not allow for recording of a partner or defacto relationship on the Death Certificate. However if you want to record it here, please complete these details.

If currently married

To Whom Married ( if wife include maiden name )::

Spouses date of Birth

Your age at Marriage

Place of Marriage

Previous Marriage (1)

To Whom Married ( if wife include maiden name )::

Spouses date of Birth

Your age at Marriage

Place of Marriage

Previous Marriage (2)

To Whom Married ( if wife include maiden name )::

Spouses date of Birth

Your age at Marriage

Place of Marriage

Burial

Cremation

Furneral Service at:

Church

Funeral Home Chapel

Home

Other Location