*** Transcriber's Note: Please set your voice synthesiser to read most punctuation. When you encounter the caret sign (^) at the end of a line, please enter the applicable information, if necessary. *** Department of Internal Affairs – Te Tari Taiwhenua BDM28 Te whakamohio i te mate mo te rehita Notification of a death Use this form to register a death if you are: • a funeral director • a person other than a funeral director responsible for organising the burial, cremation or other disposal of body of the deceased, or • an authorised agent of the person responsible for organising the burial, cremation or other disposal of body of the deceased. You need to register the death with Births, Deaths and Marriages within 3 working days of the burial, cremation or other disposal of body. It is an offence, punishable by a fine, to fail to register a death. You must get a copy of the form that states the causes of the person’s death from the health practitioner who completed it. This will be a: • HP4720 Medical Certificate of Cause of Death • HP4721 Medical Certificate of Causes of Fetal and Neonatal Death, or • Cor 3 Coroner’s Authorisation for Release of Body. Send the HP4720, HP4721 or Cor 3 in with this BDM28 Notification of death for registration form. The Department of Internal Affairs will correct the deceased’s name, date and place of birth if they are different from the deceased’s New Zealand birth record. Instructions for recording the cause of death If a HP4720 Medical Certificate of Cause of Death or a HP4721 Medical Certificate of Causes of Fetal and Neonatal Death is given to you, fill in the following as stated on the certificate: • the date and place of death • all the cause(s) of death in the same order as they are stated on the medical certificate, including Parts 1 and 2 and the approximate interval between onset and death • the name of certifying doctor • the date last seen alive by certifying doctor on page 4. If a Cor 3 Coroner’s Authorisation for Release of Body is given to you: • write the date of death as stated on the certificate on page 3 • write the place of death to the best of your knowledge on page 3 • write the cause or causes of death as ‘Subject to coroner’s findings’ and the place in which the coroner is based on page 4 • place a dash (-) in the form fields ‘Name of certifying doctor’ and ‘Date last seen alive by doctor’ on page 4. End of Life Choice Act 2019 If the subject of this death registration was eligible for assisted dying under the End of Life Choice Act 2019, this will be reflected on the HP4720 Medical Certificate of Cause of Death. Follow the same instructions above for entering a death where the cause of death was assisted dying. Include all of the same information exactly as stated on the medical certificate. De facto relationships It is important that you know whether or not the deceased was in a de facto relationship before you fill out ‘Section 4: Relationship details of deceased’ of this form. Not every relationship where two people live together (and aren’t married, or in a civil union) is a de facto relationship under the law. Being considered to be in a de facto relationship depends on a number of things, including: • the couple’s circumstances, including their ages • the length of their relationship • how committed the couple are to a sharing a life together, and • how public they make their relationship to friends and family. If you are unsure, you should get advice from a lawyer. How to submit this form Post the HP4720, HP4721 or Cor 3 and this form to: Death Registration team PO Box 10-526 Wellington 6140 New Zealand Further information Website: govt.nz/bdm/contactus Email: bdm.nz@dia.govt.nz Only use email for queries about the form. To return the form, follow the postage instructions above. Do not email the completed form to us. Privacy statement The information sought on this form is collected under the Birth, Death, Marriages, and Relationships Registration Act 2021 (the “BDMRR Act”) and is required to register the death. If this information is so registered, it will be held on a public register, and may generally be accessed by any person on application (for example, as a certificate or printout). Births, Deaths, and Marriages may also release it to certain government agencies, as authorised by law. The Privacy Act 2020 provides rights of access to, and correction of, personal information collected on this form. However, the BDMRR Act governs access to registered death information. Information about your rights to access and, where appropriate, correct the information, is available by contacting Births, Deaths and Marriages. True statements All questions on this form must be answered truthfully. It is an offence to give false information. Section 1: The deceased 1. Deceased’s name First and middle names ^ Surname or family name ^ First and middle names at birth (if different) ^ Surname or family name at birth (if different) ^ 2. Date and place of death Date of death (dd/mm/yyyy) ^ Place of death in full ^ 3. Cause or causes of death Write as stated on the HP4720 Medical Certificate of Cause of Death, HP4721 Medical Certificate of Causes of Fetal and Neonatal Death, or Cor 3 Coroner’s Authorisation for Release of Body. Part 1(a): Direct cause including interval between onset and death Direct cause ^ Approx. interval between onset and death ^ Part 1(b): Antecedent cause including interval between onset and death Antecedent cause ^ Approx. interval between onset and death ^ Part 1(c): Underlying condition including interval between onset and death Underlying condition ^ Approx. interval between onset and death ^ Part 2: Other significant contributing conditions including interval between onset and death Other significant contributing conditions ^ Approx. interval between onset and death ^ 4. Certifying doctor’s details Name of certifying doctor ^ Date last seen alive by doctor (dd/mm/yyyy) ^ 5. Deceased’s sex marker (choose from female, male or non-binary) ^ 6. Deceased’s age. Date of birth (dd/mm/yyyy) ^ Age. Enter complete years. If under 1 year old, use complete months, weeks, days, hours, minutes. ^ 7. Deceased’s place of birth Town or city ^ Country ^ 8. If the deceased was not born in New Zealand, how many years have they lived here? Number of years ^ 9. Deceased’s usual residential address Street number and name ^ Suburb or locality ^ Town, city or district ^ Postcode ^ Country (if not New Zealand) ^ 10. Deceased’s occupation Usual occupation, profession or job of deceased. Enter the occupation or job title. You do not need to include the name of the employer. For example, ‘Engineer’. If the deceased was not employed, you can enter ‘Unemployed’. If the deceased was retired at the time of their death, enter their most recent occupation. If the deceased was a medical professional (for example, a doctor, dentist or radiologist) or social worker, make sure to fill in this field. The Department of Internal Affairs is required by law to notify specific organisations when a medical professional or social worker dies. Occupation ^ 11. Is the deceased the descendant of a New Zealand Māori? Yes, no or unknown ^ 12. What ethnic group or groups does the deceased belong to? For example, NZ European, Māori, Samoan, Cook Islands Māori. ^ 13. Date and place of burial, cremation or other disposal of body The place can be in New Zealand, or a proposed place outside New Zealand to which the body will be moved to. If the proposed place is outside New Zealand, write the date that the body will leave New Zealand in the ‘Date’ field. Date (dd/mm/yyyy) ^ Place ^ 14. Was the deceased a marriage or civil union celebrant? Yes or no ^ 15. Was the deceased a Justice of the Peace? Yes or no ^ 16. Did the deceased hold an honour or award? For example, Member of the Order of Merit. Do not include military decorations. Yes or No ^ If yes, what was the name of the honour(s) or award(s) ^ Section 2: Children of the deceased 17. Living children of deceased Age of each daughter ^ Age of each son ^ Age of each non-binary child ^ 18. Children who have died before the deceased Age of each daughter ^ Age of each son ^ Age of each non-binary child ^ Section 3: Parents of the deceased 19. Parent 1 Is Parent 1 the Mother or Father? ^ First and middle names ^ Surname or family name ^ First and middle names at birth (if different) ^ Surname or family name at birth (if different) ^ Occupation ^ 20. Parent 2 Is Parent 2 the Mother, Father or Other Parent? ^ First and middle names ^ Surname or family name ^ First or middle names at birth (if different) ^ Surname or family name at birth (if different) ^ Occupation ^ Other parent details (if applicable) Where the deceased was born as a result of an assisted human reproduction procedure (such as artificial insemination), the details of Parent 2 in this section should be completed as follows: Situation 1: If the deceased’s mother was married to, or in a civil union or de facto relationship with a man who consented to the mother undergoing the procedure, that man’s details should be entered as ‘Parent 2’ in this section. Do not tick the ‘Other Parent’ box. Situation 2: If the deceased’s mother was married to, or in a civil union or de facto relationship with a woman who consented to the mother undergoing an assisted human reproduction procedure (such as artificial insemination) then tick the following box and complete the person’s details as ‘Parent 2’ in this section. Select whether the person prefers to be known as ‘Mother’ or ‘Other Parent”. Does situation 2 apply? Yes or no ^ Section 4: Relationship details of the deceased 21. Relationship details at time of death Deceased was married. Yes or no ^ Deceaesd was in a civil union. Yes or no ^ Deceased was in a marriage or civil union that was dissolved at time of death. Yes or no ^ Deceased was in a de facto relationship. Yes or no ^ Deceased's spouse or partner is also dead. Yes or no ^ Deceased was separated from de facto partner. Yes or no ^ Deceased was permanently separated from their marriage or civil union partner. yes or no ^ Deceased was never in a legal relationship. Yes or no ^ 22. Details of most recent relationship (if any) 22a. Was the relationship a marriage, civil union or de facto relationship? ^ 22b. Spouse or partner’s details In the case of a marriage or civil union, write the spouse or partner's name at the time the relationship was formalised. Spouse or partner’s first and middle names ^ Spouse or partner’s surname or family name ^ Spouse's sex (female, male, or non-binary) ^ Spouse or partner’s current age (if living) ^ 22c. Other details, if the relationship was a marriage or civil union Age of deceased at time of marriage/civil union ^ Place of marriage or civil union (include town or city and country) ^ 23. Details of second most recent relationship (if any) 23a. Was the relationship a marriage, civil union or de facto relationship? ^ 23b. Spouse or partner’s details In the case of a marriage or civil union, write the spouse or partner's name at the time the relationship was formalised. Spouse or partner’s first and middle names ^ Spouse or partner’s surname or family name ^ Spouse's sex (female, male, or non-binary) ^ Spouse or partner’s current age (if living) ^ 23c. Other details, if the relationship was a marriage or civil union Age of deceased at time of marriage/civil union ^ Place of marriage or civil union (include town or city and country) ^ 24. Details of third most recent relationship (if any) 24a. Was the relationship a marriage, civil union or de facto relationship? ^ 24b. Spouse or partner’s details In the case of a marriage or civil union, write the spouse or partner's name at the time the relationship was formalised. Spouse or partner’s first and middle names ^ Spouse or partner’s surname or family name ^ Spouse's sex (female, male, or non-binary) ^ Spouse or partner’s current age (if living) ^ 24c. Other details, if the relationship was a marriage or civil union Age of deceased at time of marriage/civil union ^ Place of marriage or civil union (include town or city and country) ^ 25. Details of fourth most recent relationship (if any) 25a. Was the relationship a marriage, civil union or de facto relationship? ^ 25b. Spouse or partner’s details pouse or partner’s details In the case of a marriage or civil union, write the spouse or partner's name at the time the relationship was formalised. Spouse or partner’s first and middle names ^ Spouse or partner’s surname or family name ^ Spouse's sex (female, male, or non-binary) ^ Spouse or partner’s current age (if living) ^ 25c. Other details, if the relationship was a marriage or civil union Age of deceased at time of marriage/civil union ^ Place of marriage or civil union (include town or city and country) ^ Section 5: Person notifying the death 26. Your profession or occupation Occupation ^ 27. Your full name ^ 28. Your contact details Phone number ^ Email ^ 29. Your address Street number and name ^ Suburb or locality ^ Town, city or district ^ Postcode ^ Country (if not New Zealand) ^ 30. Your signature ^ Date signed (dd/mm/yyyy) ^ Section 6: Death certificate (optional) 31. Write the quantity of death certificates you need ^ 32. Death certificate delivery Select a delivery method: I want the certificate(s) sent by standard post $0. Yes or no ^ I want the certificate(s) couriered to a New Zealand address $5. Yes or no ^ I want the certificate(s) couriered to an overseas address $15 - $30. Yes or no^ The courier cost to Australia, Asia, and Pacific is $15. The courier cost to the USA is $20. The courier cost to Europe is $25. The courier cost to the rest of world is $30. This includes Azerbaijan, Armenia, Bulgaria, Bosnia and Herzegovina, Cyprus, Croatia, Greece, Georgia, Macedonia, Malta, and Moldova. Contact us if you are unsure whether we can deliver to your country. Contact information is in part 1. Delivery address: Delivery name ^ Street number and name ^ Suburb ^ Town or city ^ Country ^ Postcode ^ 33. Death certificate payment Do not post cash or card. Do not email credit card details. Charge my credit or debit card (Visa, MasterCard, American Express, Prezzy Card). Card number ^ Card expiry date ^ Name on card ^ Cardholder signature ^ End of form. Last updated 13 May 2024.