1
PERSOONLIJKE GEGEVENS (deze zijn nodig bij het doen van aangifte van overlijden bij de gemeente)
Naam
............................................................................................................................................
Voornamen
............................................................................................................................................
Adres
............................................................................................................................................
Postcode en woonplaats
............................................................................................................................................
Geboortedatum
............................................................................................................................................
Geboorteplaats
............................................................................................................................................
Gehuwd met
............................................................................................................................................
Gescheiden van
............................................................................................................................................
Weduwe/weduwnaar van ............................................................................................................................................ Nationaliteit
............................................................................................................................................
Levensovertuiging
............................................................................................................................................
KINDEREN
aantal: .............................
Bij minderjarige kinderen de namen, voornamen, geboortedatum en geboorteplaats vermelden 1 ............................................................................................................................................................................. 2 .............................................................................................................................................................................. 3 ..............................................................................................................................................................................
EEN ERFGENAAM Naam
............................................................................................................................................
Adres
............................................................................................................................................
Postcode en woonplaats
............................................................................................................................................
CONTACTPERSOON DIE DE UITVAART VOOR MIJ REGELT Naam
............................................................................................................................................
Adres
............................................................................................................................................
Postcode & woonplaats
............................................................................................................................................
Telefoon
............................................................................................................................................ TUMULUS Uitvaartverzorging
2
BELANGRIJKE GEGEVENS
Huisarts
............................................................................................................................................
Adres
............................................................................................................................................
Postcode & woonplaats
............................................................................................................................................
Telefoon
............................................................................................................................................
TESTAMENT GEMAAKT
❒ ja
❒ nee
Notaris
............................................................................................................................................
Adres
............................................................................................................................................
Postcode & woonplaats
............................................................................................................................................
Telefoon
............................................................................................................................................
DONORCODICIL
❒ ja
❒ nee
UITVAARTVERZEKERING
❒ ja
❒ nee
❒ natura
❒ deposito
Maatschappij
............................................................................................................................................
Polisnummer
............................................................................................................................................
Adres
............................................................................................................................................
Postcode & woonplaats
............................................................................................................................................
Telefoon
............................................................................................................................................
GEGEVENS WERKGEVER / PENSIOENFONDS / AOW / UITKERINGSINSTANTIE Naam
............................................................................................................................................
Adres
............................................................................................................................................
Postcode & woonplaats
............................................................................................................................................
Telefoon
............................................................................................................................................
TUMULUS Uitvaartverzorging
3
BELANGRIJKE PAPIEREN
❒ Bank / Girobescheiden .............................................................................................................................................. ❒ Contracten ................................................................................................................................................................ ......................................................................................................................................................................................... ❒ Testament ................................................................................................................................................................. gemachtigde ............................................................................................................................................................... ❒ Donorcodicil ❒ Verzekeringspapieren maatschappij
soort
polisnummer
........................................................
.................................................................
.............................................
........................................................
.................................................................
.............................................
........................................................
.................................................................
.............................................
.......................................................
.................................................................
.............................................
❒ Andere, nl. ................................................................................................................................................................ ❒ Andere, nl. ................................................................................................................................................................
OP WELKE PLAATS? ................................................................................................................................................... ..........................................................................................................................................................................................
ABONNEMENTEN ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... LIDMAATSCHAPPEN ......................................................................................................................................................................................... ......................................................................................................................................................................................... ......................................................................................................................................................................................... .........................................................................................................................................................................................
TUMULUS Uitvaartverzorging
4
WENSEN BETREFFENDE MIJN BEGRAFENIS/CREMATIE MIJN WENS IS TE WORDEN
❒ begraven
❒ gecremeerd
DE UITVAART VINDT PLAATS ❒ met familie, vrienden en belangstellenden ❒ met familie en vrienden
ROUWBRIEVEN
❒ wel
❒ met alleen door mij gekozen genodigden
❒ niet versturen
type ......................................................................................................................................................................
ADVERTENTIE
❒ niet plaatsen
❒ wel plaatsen
in .................................................................................
editie .............................................................
in ................................................................................
editie .............................................................
GEDACHTENISPRENTJE
❒ wel
❒ niet
type .....................................................................................................................................................................
OPBARING
❒ thuis ❒ uitvaartcentrum ..................................................................................................
andere wensen ..................................................................................................................................................... .............................................................................................................................................................................
KIST
❒ spaanplaat ❒ massief hout type ............................................................................................. gewenste bekleding ...................................................................................................
BAAR
❒ massief hout type ................................................................................................
Gewenste kleding ................................................................................................................................................ ............................................................................................................................................................................. anders, nl. .......................................................................................................................................................... .............................................................................................................................................................................
TUMULUS Uitvaartverzorging
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BEZOEKREGELING
❒ thuis
❒ rouwcentrum
❒ op afspraak
❒ tijden ......................................................................
❒ vrij speciale wensen ............................................................................................................................................ .......................................................................................................................................................................
BLOEMEN
❒ wel
❒ geen
speciale wensen ............................................................................................................................................ .......................................................................................................................................................................
VERVOER
❒ wel
❒ geen rouwauto
❒ wel
❒ geen volgauto
speciale wensen ............................................................................................................................................ .......................................................................................................................................................................
DRAGERS
❒ eigen familie / vrienden ❒ dragers van uitvaartonderneming
KERKELIJKE UITVAART
❒ niet
❒ wel, kerk .............................................................................
WENSEN T.A.V. DE HERDENKINGSDIENST plaats ............................................................................................................................................................ muziek ......................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... spreker(s) ..................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... speciale wensen ............................................................................................................................................ ....................................................................................................................................................................... .......................................................................................................................................................................
TUMULUS Uitvaartverzorging
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NA DE UITVAART
❒ wel
❒ geen bijeenkomst
Condoleance ................................................................................................................................................. wensen t.a.v. de consumpties ...................................................................................................................... ....................................................................................................................................................................... .......................................................................................................................................................................
GRAFMONUMENT omschrijving ............................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... steenhouwer ................................................................................................................................................ kunstenaar ...................................................................................................................................................
URN
omschrijving ................................................................................................................................................. .......................................................................................................................................................................
UITVAART LATEN VERZORGEN DOOR Naam onderneming: .................................................................................................................................... Adres: ........................................................................................................................................................... Postcode en woonplaats ..............................................................................................................................
TUMULUS Uitvaartverzorging
7
DE CREMATIE
Crematorium
............................................................................................................................................
Opbaring in de aula
............................................................................................................................................
....................................................................................................................................................................... ........................................................................................................................................................................ Afscheidsritueel
............................................................................................................................................
........................................................................................................................................................................ ........................................................................................................................................................................
Invoeren oven
❒ wel
ASBESTEMMING
❒ verstrooiing op het strooiveld van het crematorium ❒ zonder
❒ niet
❒ met familie/vrienden
❒ verstrooiing op zee per boot ❒ verstrooiing op zee per vliegtuig ❒ bijzetting in het graf van .............................................................................................. ❒ bijzetting columbarium ❒ urnengraf ❒ eigen bestemming
speciale wensen ............................................................................................................................................. ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... .......................................................................................................................................................................
TUMULUS Uitvaartverzorging
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DE BEGRAFENIS
BEGRAAFPLAATS
............................................................................................................................................ ❒ graf aanwezig; nummer ................................................................................................. rechthebbende van dit graf ........................................................................................... adres ............................................................................................................................. postcode & woonplaats ................................................................................................. ❒ geen graf aanwezig ❒ familiegraf voor
❒ 1
❒ 2
❒ 3 personen
voor ................. jaar
AULA
❒ niet
❒ wel
AFSCHEIDSRITUEEL BIJ HET GRAF ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... .......................................................................................................................................................................
KIST
❒ dalen ❒ blijven staan
speciale wensen .............................................................................................................................................. ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... ....................................................................................................................................................................... .......................................................................................................................................................................
TUMULUS Uitvaartverzorging
9
TEKST ROUWBRIEF
..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... .................................................................................................................................................................................... .................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... .....................................................................................................................................................................................
TUMULUS Uitvaartverzorging
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EVENTUELE ANDERE WENSEN
..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... ..................................................................................................................................................................................... .....................................................................................................................................................................................
TUMULUS Uitvaartverzorging
11
KOSTENOPGAVE Uitvaart: ........................................................................................................
reg.nr: .............................
Vervulling van de wettelijke formaliteiten en alle door ons te verrichten diensten. BASISTARIEF INCLUSIEF KANTOORKOSTEN
€ .....................................
GETAXEERDE KOSTEN VAN DIVERSE DOOR ONS INGEHUURDE DIENSTEN Ook voor nog niet ingevulde bedragen geldt de factuur van de betreffende bedrijven. Vervoer overledene ....................................................................................................
€ .....................................
Volgwagen(s) ............................................................................................................
€ .....................................
Avond / weekendtoeslag / extra wachttijd personeel ............................................
€ .....................................
Dragersgroep ............................................................................................................
€ .....................................
Rouwbrieven exclusief porti .....................................................................................
€ .....................................
Herinneringsprentjes ................................................................................................
€ .....................................
Dankbetuigingskaarten ............................................................................................
€ .....................................
Advertentie (s) ..........................................................................................................
€ .....................................
Kist inclusief bekleding .............................................................................................
€ .....................................
Baar ...........................................................................................................................
€ .....................................
Rouwcentrum ...........................................................................................................
€ .....................................
Bedkoeler ...................................................................................................................
€ .....................................
Ziekenhuiskosten / extra verzorgingskosten ..............................................................
€ .....................................
Kerk, avondwake ......................................................................................................
€ .....................................
Vergoeding pastoor, dominee, humanistisch spreker .................................................
€ .....................................
Kosten begraafplaats / crematorium ..........................................................................
€ .....................................
Gebruik koffiekamer en consumpties .......................................................................
€ .....................................
Muziek ......................................................................................................................
€ .....................................
Bloemschikking ........................................................................................................
€ .....................................
Overlijdensakte ........................................................................................................
€ .....................................
Condoleanceboek .....................................................................................................
€ .....................................
Gids na een overlijden ..............................................................................................
€ .....................................
TOTAAL GETAXEERDE KOSTEN
€ .....................................
TUMULUS Uitvaartverzorging
