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A.

Registered Name :

B.

Your Profession or Occupation :

C.

Usual Residence :

D.

Date Of Birth :

Born:

E.

Full Name and Surname of Father :

F.

Profession of Father :

G.

Full Name and Surname of Mother :

H.

Maiden Name Of Mother :

I.

Profession of Mother :

J.

If deceased was married

To Whom (Full Name / Maiden Name)

Age At Marriage

Place Of Marriage

1st

2nd

3rd

K.

Children :

Female :

Male :

L.

Wife

Husband

Age:

(If Living)

M.

European

Maori

Other :

N.

Holder Of Title : EG JP, MP, OBE

Title,

J.P. O.B.E. M.P.

O.

Other honour or award (Not Military)