This form is to be used when ordering an Upcoming Listing - First Service Only
Staff Member
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Bernie Moloney
Bernie Magher
Beth King
Julie Stabernack
Louise King
Sanja Dosen
Tricia Van Grondelle
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Date of Death
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Funeral Type
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Funeral
Memorial Service
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Private Funeral
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Burial or Cremation
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Burial
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Funeral Date
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Funeral Time
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Hour
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PM
Funeral Venue (Test)
All Saints Anglican Church
Altona Memorial Park
Eastern Cemetery
Geelong Memorial Park
Highton Cemetery
Holy Family Catholic Church
Holy Spirit Catholic Church
Kings Chapel (Newcomb)
Kings Chapel (Geelong City)
Lyndon Grove Receptions
Queenscliff Cemetery
Rice Village Aged Care Chapel
Springvale Botanical Cemetery
St Frances Xavier Church
St Peters and Pauls Church
St Bernard’s Catholic Church
St Margaret’s Church
St Mary's Basilica
St Therese Catholic Church
St Thomas Aquinas
Our Lady's Ukrainian Catholic Church
Our Lady Star of the Sea Catholic Church
Western Cemetery
Other
Funeral Venue
All Saints Anglican Church
Altona Memorial Park
Eastern Cemetery
Geelong Memorial Park
Highton Cemetery
Holy Family Catholic Church
Holy Spirit Catholic Church
Kings Chapel (Newcomb)
Kings Chapel (Geelong City)
Lyndon Grove Receptions
Queenscliff Cemetery
Rice Village Aged Care Chapel
Springvale Botanical Cemetery
St Frances Xavier Church
St Peters and Pauls Church
St Bernard’s Catholic Church
St Margaret’s Church
St Mary's Basilica
St Therese Catholic Church
St Thomas Aquinas
Our Lady's Ukrainian Catholic Church
Our Lady Star of the Sea Catholic Church
Western Cemetery
Other
Funeral Address (Test)
Other Funeral Venue
Other Funeral Address
Additional Funeral Details
Donations
No Donations
In lieu of flowers, donations may be made to the Asthma Australia. Envelopes will be available at the Funeral.
In lieu of flowers, donations may be made to Australian Red Cross. Envelopes will be available at the Funeral.
In lieu of flowers, donations may be made to Beyondblue. Envelopes will be available at the Funeral.
In lieu of flowers, donations may be made to Barwon Health. Envelopes will be available at the Funeral.
In lieu of flowers, donations may be made to Bowel Cancer Australia. Envelopes will be available at the Funeral.
in lieu of flowers, donations may be made to CanTeen. Envelopes will be available at the Funeral.
In lieu of flowers, donations may be made to Cancer Council of Victoria. Envelopes will be available at the Funeral.
In lieu of flowers, donations may be made to Diabetes Australia. Envelopes will be available at the Funeral.
In lieu of flowers, donations may be made to the Heart Foundation. Envelopes will be available at the Funeral.
In lieu of flowers, donations may be made to Multiple Sclerosis Australia. Envelopes will be available at the Funeral.
In lieu of flowers, donations may be made to National Breast Council Australia. Envelopes will be available at the Funeral.
In lieu of flowers, donations may be made to Ovarian Cancer Australia. Envelopes will be available at the Funeral.
In lieu of flowers, donations may be made to Sids and Kids. Envelopes will be available at the Funeral.
In lieu of flowers, donations may be made to The Royal Children's Hospital Foundation. Envelopes will be available at the Funeral.
Other
Donations (Other)
Memorial Time
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Hour
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PM
Memorial Date
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Month
2016
2015
2014
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Year
Memorial Venue
Memorial Address
Burial Location
Burial Address
Additional Burial Details (if required)
Cremation Location
Geelong Memorial Park
Other
Cremation Location (Other)
Cremation Address (Other)
Cremation Address
Additional Cremation Details (if required)
Responsible Person First Name
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Responsible Person Last Name
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Responsible Person email address
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Responsible Person Phone Number
Responsible Person Relationship
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Father
Son
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Extended Family
Friend
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Is there an additional Responsible Person?
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Second Responsible Person First Name
Second Responsible Person Last Name
Second Responsible Person email address
Second Responsible Person Phone Number
Second Responsible Person Relationship
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Husband
Mother
Father
Son
Daughter
Sister
Brother
Partner
Extended Family
Friend
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Third Responsible Person First Name
Third Responsible Person Last Name
Third Responsible Person email address
Third Responsible Person Phone Number
Third Responsible Person Relationship
Wife
Husband
Mother
Father
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Extended Family
Friend
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Fourth Responsible Person First Name
Fourth Responsible Person Last Name
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Fourth Responsible Person Relationship
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Special Comments/Instructions
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