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I (Full Name)

(the undersigned)

of (Address)

wish it known, that

On the event of my death, I desire the following :

DIGNITY WITH SINCERITY FUNERAL SERVICES

be contacted to carry out all necessary arrangements for my FUNERAL and THAT

instructions concerning this matter are held at their office.

1

Cremation At :

Harewood Crematorium

Canterbury Crematorium

Burial At :

2

Any Religious Affiliation :

3

Funeral Service to be held at:

4

Casket Choice :

Simple

Maple

Rimu

Oak

Mahogany

5

Newspaper Notice :

Before

After

Press

Star

Other :

6

In Lieu of Flowers, Donations To :

7

Extended invitation :

Lodge

RSA

Other :

8

Special instructions :

9

Next of Kin (Name & Address) :

10

Funeral Expense Account to

If Pre-paid - Amount :

$

Dated :

Signature :