Interment Form
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1Interment Form
CODC – Alexandra
CODC – Cromwell
CODC - Ranfurly
Fax:
03 448 9196
Fax:
03 445 1649
Fax:
03 444 9166
A/H Service:
03 440 0056
A/H Service:
03 445 0211
A/H Service:
03 444 9857
A/H Phone:
027 328 1100
A/H Phone:
027 437 4538
A/H Phone:
027 274 0088
If you wish to email this form to us please scan to PDF send to cemeteries@codc.govt.nz
Interment Warrant
Cemetery: __________________________________________ Plot: ________________ Block: ________
New Plot
Double Depth
Single
Reserved
Ashes
Reopening
______________________________________ Cemetery Record #: __________________
(Details)
(C/R)
Person to be Interred: _________________________________
__________________________________
Surname
First name/s
Date of Death: ________________ Age: _________________ Occupation: ________________________
Next of Kin: ____________________________ Late Residence: __________________________________
Where Deceased Came From: ______________________________________________________________
Native of: ____________________________________ Relation to Plot Owner: _______________________
Time of Funeral: ______________________________ Date of Funeral: _____________________________
(Day)
(Date)
Expected Time of Interment at the Cemetery ___________________________________________________
Certified by: ___________________________________________________ Date: ____________________
(Funeral Director or Person Organising Interment)
Note: If the interment is not organised by a funeral director the following supporting documentation must be supplied: HP4720
(medical certificate of cause of death) or HP4721 (medical certificate of cause of foetal and neonatal death) or COR3 (coroners
authorisation for release of body). Ash interments are exempt from these requirements.
Address for Invoice _______________________________________________________________________
Special Instructions: ______________________________________________________________________
______________________________________________________________________________________
Plot Reservation Details
N/A
Double Depth
Side by Side
Reserved Plot/s
#
Ash Plot/s
#
Owners Name/Address:
Plot #
Block #
C/R #
Warrant – Sexton to Bury in Cemetery
The Sexton in charge of the Cemetery is authorised to bury as above, the Body of the late:
______________________________________________________________________________________
The Body was buried by me on the: ______________________________ at: ___________ 20 _________
(Date)
(Time)
(Year)
Signed: ____________________________________________________
__________________________
(Sexton)
(CODC Authorised Officer)
Additional Plot Information _________________________________________________________________
______________________________________________________________________________________
Interment Form
Invoice # ________________ Other Family Records (C/R#) _______________________________
Revised 03/16
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