Intake form general

Data concerning who is involved

Genus:

Surename:

Given names:

Adress and number:

Zip code:

Place:

BSN number:

Date of birth:

Birthplace:

Weight:

Length:

Pacemaker present:

id/passport front:

id/passport back

Death data (if known).

Indication of period of death:

Date of death:

Time of death:

Location of death:

Address and house number of location:

Location zip code:

Location location:

Floor:

Elevator available:

Client/Contact Person

Relationship to deceased:

Surename:

Given names:

Home address and house number:

Zip code:

Place:

Date of birth:

Phone number:

id/passport front

id/passport back

Country of repatriation:

Place

Contact:

Address:

Poscode if present:

Phone number:

Email:

Additional information

I give permission to the funeral director to use the above data for the funeral and, where necessary, to share it with parties in order to be able to carry out the funeral properly (e.g. sharing data with the municipality and e.g. a crematorium or cemetery).*

Signature

Bij overlijden bel: 085-1306447

Wilt u een repatriëring melden? vul ons intake formulier in.

Hoofdkantoor

Kantoor België

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