Interment Permit Application

Application form for all interments in cemeteries within the Dubbo Regional Council LGA.

Name* - required

Business Name* - required

ABN* - required

Address Line 1* - required

Address Line 2

City State Postcode* - required

Contact telephone number* - required

Email* - required

Location of cemetery* - required

Dubbo Town Wellington Town Any Village

Name of Deceased* - required

Last known address of deceased* - required

Occupation of deceased* - required

Gender* - required

Male Female

Age

Date of death* - required

Date of Birth* - required

Next of kin - First Name* - required

Next of kin - Middle Name* - required

Next of kin - Surname/Family Name* - required

Next of Kin - Address Line 1* - required

Next of Kin - Address Line 2

Next of Kin - City State Postcode* - required

Next of Kin - Contact telephone number* - required

Next of Kin Relationship* - required

Applicant - First Name* - required

Applicant - Middle Name* - required

Applicant - Surname/Family Name* - required

Applicant - Address Line 1* - required

Applicant - Address Line 2

Applicant - City State Postcode* - required

Applicant - Contact telephone number* - required

Applicant - Relationship* - required

Coffin Size* - required

Large Oversize Adult - 2200L x 800W x 450D (including handles) Oversize Adult - 2040L x 700W x <400D (including handles) Small - Child / Baby - put size into comments Standard Adult - 2040L x 660W x <400D (including handles)

Coffin size comments

Single or Double Depth* - required

Single depth Double depth Re-opening

Date of Interment* - required

Set up time at Cemetery* - required

Service* - required

Time of Church Service - if applicable

Expected time of Interment* - required

Estimated time of family / funeral staff departure:* - required

Plots requested to be placed on hold for family

Name

Address

Telephone Number

Mandatory field(s) marked with *

Interment Permit Application

Interment Permit Application

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ACKNOWLEDGEMENT