Online Submission
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Mosaic Funeral Group Pinetown's Welcomes You
Mosaic Funeral Group Pinetown's Online Form
The following form will contain 4 sections:
1) Informant - About you.
2) Deceased - Your loved one.
3) Consent and Agreements.
4) Services.
If you have any questions or need assistance contact:
Jacques - click on link below:
WhatsApp
Call Now
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Informant - All About You
Informant is the term used to describe the person responsible for the arrangements. They can be a next of kin or even a friend. The family have appointed you to make the arrangements on their behalf.
*Full Names (Include Names and Surname)
*Address
*Phone Number
*ID Number
*Email
*Your Relationship to the Deceased
You can upload your ID below. Click on the upload icon to browse your device.
If you have the green barcoded ID book, please include both pages of the ID within the image (see sample image below). This image will be converted into a scan and presented to Home Affairs. Home Affairs will not accept one sided ID copies. For ID cards, just the front will be sufficient.
Upload Your ID Here:
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doc,docx,mpg,mpeg,mp3,mp4,odt,odp,ods,pdf,ppt,pptx,txt,xls,xlsx,jpg,jpeg,png,psd,tif,tiff
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Thank you
{{informant_names}}
for submitting your info.
Please confirm if the following information is correct:
Address:
{{informant_address}}
Phone Number:
{{informant_phone}}
ID Number:
{{informant_id}}
Email:
{{informant_email}}
You are the -
{{informant_relation}}
of the
deceased.
If the above information is correct, please click next. To correct information, please click back and correct the information required.
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Deceased Information
This is the section for the deceased information. Please complete the fields below
*Full Names (Deceased Names and Surname)
*Last Known Address
*ID Number
*Marital Status
-Select-
Single
Married
Divorced
Widow / Widower
*Gender
-Select-
Male
Female
*Occupation
*Place of Death (Area)
*Date of Death
*Brief Medical History
If you have the green barcoded ID book, please include both pages of the ID within the image (see sample image below). This image will be converted into a scan and presented to Home Affairs. Home Affairs will not accept one sided ID copies. For ID cards, just the front will be sufficient.
Upload Deceased ID (Click on upload icon):
X
doc,docx,mpg,mpeg,mp3,mp4,odt,odp,ods,pdf,ppt,pptx,txt,xls,xlsx,jpg,jpeg,png,psd,tif,tiff
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We are so sorry to hear about the passing of
{{deceased_name}}
.
Please confirm if the below information is correct. Click back to make corrections if required. Click next to proceed.
Address:
{{deceased_address}}
ID Number:
{{deceased_id}}
Gender:
{{deceased_gender}}
Date of Death:
{{deceased_date}}
Place of Death:
{{deceased_place}}
Occupation:
{{deceased_occ}}
Medical History:
{{deceased_medical}}
Marital Status:
{{deceased_status}}
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Consent and Agreements
Your consent below is required in order to proceed from our side. Some fields only have one option. This is because this answer is required in order to proceed. If at any point the answer is not correct, please contact us immediately. We will advise you on the process that will have to be followed before we can continue.
Direction - this confirms that cremation is the wishes of the deceased and family
*The deceased left a Written Will or verbal direction for:
-Select-
Cremation
*Will the family object to cremation?
-Select-
No
Natural Causes of death is when no postmortem will be conducted.
Unnatural Causes - a postmortem has to take place to determine the causes of death.
*I have no reason to suspect that the causes of death were other than natural:
-Select-
No Doubt
I have doubt - Postmortem to be conducted
*I desire a postmortem to be conducted:
-Select-
I do not
Postmortem to take place
a Pacemaker has a battery within and may explode in the furnace if not removed before cremation.
*Did the Deceased have a Pacemaker?
-Select-
Yes
No
*I consent to surgical removal of the pacemaker.
-Select-
Yes
Not Applicable - No Pacemaker
Registration of Death - Home Affairs
Mosaic Funeral Group Pinetown can attend to the registration of death on your behalf. Please be aware that the Registrar of Death within the company will only attend to registration on certain days. You can register at Home Affairs on your own accord if death registration is urgently required.
Please be aware that Home Affairs print the death certificate from their database which may be incorrect, pertaining to the marital status.
*1) I understand that the death certificate may be incorrect.
-Select-
I understand
*2) Only the family can go to Home Affairs to have the status amended.
-Select-
I understand
*3) This is to no fault of Mosaic Funeral Group Pinetown, but printed from the Home Affairs database.
-Select-
I understand
You understand and want Mosaic Pinetown to register on your behalf.
*Registration of death at Home Affairs:
-Select-
I give permission for Mosaic Pinetown to register on my behalf.
I will go to Home Affairs myself and register the death.
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Services
We are almost done. Here you can select the cremation service type and submit the form.
We offer a wide range of services and packages. Speak to a consultant if you require something different or leave a note below and someone will be in contact with you.
Private Cremation
Private Cremation means that no coffin will go to a church or venue and nobody will attend the cremation. Pricing starts from R14 000.00
Attrending Cremation
Attended Cremation means that no coffin will go to a church or venue, but a few people would like to be at the crematorium on the day of cremation. Pricing starts from R15 500.00
Attended Church - Private Cremation
Attend Church means that a coffin will be in the church or a venue. The cremation will take place privately on a later date. This may include requirements like leaflets for the church, flowers etc. Depending on requirements, prices start from R18500.00
*I choose the following service:
-Select-
Private Cremation - starting from R14 000.00
Attended Cremation - starting from R15 500.00
Attended Church - Starting from R18 500.00
Other - i will discuss my requirements with the consultant
Basic Ash Urns
Bio Urn - R500 + VAT
Scatter Urn - Included
Stained Pine - R500 + VAT
Plain Pine - R500 + VAT
Rosewood - R500 + VAT
Kiaat - R500 + VAT
*I choose to following urn to go with the above service:
-Select-
Bio Urn - I want to plant a tree / flowers in remembrance of my loved one.
Scatter Urn - I will be scattering the ashes.
Wooden urn - Pine
Wooden Urn - Kiaat
Wooden Urn - Rosewood
Wooden Urn - Plain Pine
I hereby sign below consenting and confirming to all the information and arrangements i have made. I give Mosaic consent to proceed accordingly.
Please sign within the signature block below. Use your mouse (desktop), finger or mobile pen (mobile + tablet) to sign. Use the eraser icon to clear the box if an error was made. You can zoom in with mobile to assist your efforts.
*Signature
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