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Online Facilities.
Mosaic Funeral Group Welcomes You.
FYI: You will be referred to as the “Informant”
(Responsible person and authorised representitive to make decisions regarding the Deceased)
*Your Full Names
*Your Address
*Your Phone Number
*Your Email
*Your ID Number
Your Relationship to the Deceased:
Upload your ID Copy:
— Select —
No – Will WhatsApp / Email Later
Yes – An Image
Yes – PDF
Image Upload
gif,jpg,jpeg,png,psd,tif,tiff
File Upload
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Welcome
{{informant_names}}
.
Details provided are:
Address:
{{informant_address}}
Email:
{{informant_email}}
Relationship to Deceased:
{{relation_deceased}}
ID Number:
{{informant_id}}
Contact Number:
{{informant_number}}
If the above is correct, please continue. If not, go back to previous page.
Continue
Deceased Information
Please provide information of Deceased:
*Name of Deceased:
*Usual Address:
*ID Number:
*Gender
.
Male
.
Female
.
Other
*Usual Occupation
*Their Age:
*Marital Status
.
Single
.
Married
.
Divorced
.
Widow / Widower
*Brief Medical History – Only recent required:
*Did the Deceased have a Pacemaker?
— Select —
Yes
No
*I consent on the removal of the pacemaker
— Select —
N/A no Pacemaker
Yes
*The Deceased left a written will / verbal direction with wishes to be?
— Select —
Cremated
*Will any family object to the cremation?
— Select —
No
Place of Death
*Date of Death
*I have no reason to suspect that the causes of death were other that natural causes:
.
No Doubt
.
I have doubt / Uncertain – post-mortem to be conducted
*I desire a post-mortem examination to confirm this?
.
I do not
.
Post-mortem to take place
I hereby solemnly declare that the above mentioned is true to the best of my knowledge and no particulars have been omitted:
Zoom in on Signature for easy signing. You can only erase by clicking the “Eraser” icon, left bottom corner.
*Signature
Upload deceased ID?
— Select —
No – WhatsApp / Email Later
Yes – Image
Yes – PDF
Deceased ID Image
gif,jpg,jpeg,png,psd,tif,tiff
Deceased ID PDF
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doc,docx,mpg,mpeg,mp3,mp4,odt,odp,ods,pdf,ppt,pptx,txt,xls,xlsx
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We are almost done,
{{informant_names}}
.
Please confirm Deceased info:
Name:
{{deceased_name}}
Their usual occupation was:
{{deceased_occ}}
and was
{{deceased_status}}
The person was confirmed to have a pacemaker –
{{deceased_pacemaker}}
and passed away at
{{deceased_place}}
Address:
{{deceased_address}}
The person is
{{deceased_gender}}
was
{{deceased_age}}
years old.
Person passed away on:
{{deceased_date}}
and their ID number was
{{deceased_age}}
If the above information is correct, please continue or go back to amend on previous page.
Consent and Cremation
I hereby give Mosaic Funeral Group Pinetown consent to register the death on my behalf at Home Affairs.
*Home Affairs print from their database. Particular to the marital status, the Home Affairs database may not correspond to family records. If the marital status is incorrect on the Death Certificate, the family have to apply directly from Home Affairs for amendment of marital status. This cannot be done by the Funeral Home*
*Marital status may be incorrect on Death Certificate – Select all options to acknowledge*
—Please select all below—
I understand that the marital status on the Death Certificate may be incorrect.
The family will be required go to Home Affairs to have this amended (if incorrect).
This is to no fault of Mosaic Funeral Group, but printed from Home Affairs’ database.
Home Affairs prohibit the funeral home to apply for such amendments. (Only Family)
I hereby give Mosaic Funeral Group Pinetown consent to proceed with the following service:
*Cremation Service:
— Select —
Private Cremation – No coffin to go to church and nobody to attend cremation.
Privately Attended – Less than 10 people to attend cremation with crem staff.
Attended Church – Coffin to go to church. Cremation to take place privately on a later date.
Special Arrangements – To contact Mosaic Rep for instructions.
Urn Selection – All Urns are Included with any cremation service selected.
Scatter Urn
Legacies Bio Urn
Wooden – Pine
Wooden Rosewood
Wooden – Stain Pine
Wooden – Kiaat
HTML Links
See more on Legacies Bio Urn – Click link below
Legacies Website
*Select Urn
— Select —
Scatter Urn – Included
Legacies Bio Urn
Wooden – Pine
Wooden – Stained Pine
Wooden – Rosewood
Wooden – Kiaat
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