Persoonlijke uitvaartwensen
Zuidema’s Begrafenis Onderneming
van
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Persoonlijke wensen bij uw uitvaart Hieronder kunt u uw uitvaartwensen kenbaar maken. Deze vertrouwelijke gegevens moet u zelf dateren en ondertekenen en kunnen het beste bij andere belangrijke papieren, zoals een trouwboekje bewaard worden.
Invulling van uw persoonlijke gegevens De ondergetekende Naam: .............................................................................................................................................................................................................................................................................................................................................................................................. Voornamen: ........................................................................................................................................................................................................................................................................................................................................................................... Geboortedatum: ............................................................................................................................................................................................................................................................................................................................................................. Geboorteplaats: .............................................................................................................................................................................................................................................................................................................................................................. Geslacht: ■ man
■ vrouw
Burger Service Nummer (BSN): ............................................................................................................................................................................................................................................................................................................. Adres: .............................................................................................................................................................................................................................................................................................................................................................................................. Postcode en woonplaats: ............................................................................................................................................................................................................................................................................................................................... Telefoon: ...................................................................................................................................................................................................................................................................................................................................................................................... E-mail: .............................................................................................................................................................................................................................................................................................................................................................................................
Handtekening: ...................................................................................................................................................................................................................................................................................................................................................................
Heeft de hierna vermelde uitvaartwensen en gegevens vastgelegd.
Personalia van de opdrachtgever / executeur na overlijden Naam: .............................................................................................................................................................................................................................................................................................................................................................................................. Familieverhouding / relatie: .......................................................................................................................................................................................................................................................................................................................... Adres: .............................................................................................................................................................................................................................................................................................................................................................................................. Postcode en woonplaats: ............................................................................................................................................................................................................................................................................................................................... Telefoon: ...................................................................................................................................................................................................................................................................................................................................................................................... E-mail: .............................................................................................................................................................................................................................................................................................................................................................................................
Keuze uitvaart ■ Begrafenis ■ Crematie ■ Terbeschikkingstelling wetenschap
Kennisgeving van overlijden Versturen van rouwbrieven ■ Ja
■ Papiersoort:..............................................................................................................................................................................................................................................................................................................................
■ Eigen ontwerp
■ Voor de uitvaart versturen
■ Na de uitvaart versturen
■ Nee Adreslijst beschikbaar ■ Ja
Waar: ...........................................................................................................................................................................................................................................................................................................................................................
■ Nee Plaatsen advertentie(s) ■ Ja
Naam krant:.......................................................................................................................................................................................................................................................................................................................................
1:. .........................................................................................................................................................................................................................................................................................................................................................................
2:. .........................................................................................................................................................................................................................................................................................................................................................................
3: ........................................................................................................................................................................................................................................................................................................................................................................
■ Nee Kennisgeving via internet
■ Ja
■ Nee
Gebruik gedachtenis- of bidprentjes
■ Ja
■ Nee
Versturen dankkaartjes
■ Ja
■ Nee
Plaatsen dankadvertentie(s)
■ Ja
■ Nee
■ Ja
Naam krant:.......................................................................................................................................................................................................................................................................................................................................
1:. .........................................................................................................................................................................................................................................................................................................................................................................
2:. .........................................................................................................................................................................................................................................................................................................................................................................
3: ........................................................................................................................................................................................................................................................................................................................................................................
■ Nee Achterin vindt u enkele lege pagina’s waarop u bijvoorbeeld de tekst voor de rouwbrief kunt opschrijven. Regeling Uitvaartverzorging door: Naam: Zuidema’s Begrafenis onderneming BV Naam uitvaartleid(st)er:...................................................................................................................................................................................................................................................................................................................................... Adres: Oud-Cromstrijensedijk O.Z. 87b, 3286 BM Klaaswaal Tel: 0186-571517 / E-mail:
[email protected]
Overzicht uitvaartverzekeringen
Verzekeringsmaatschappij
Polisnummer
Bedrag / in natura
(Ook als u verzekerd bent bij Yarden, Monuta of Dela kunt u beroep op ons doen.) Naam bank:.............................................................................................................................................................................................................................................................................................................................................................................. Banknummer:........................................................................................................................................................................................................................................................................................................................................................................
Lidmaatschap crematie / uitvaartvereniging ■ Ja, nl.:
.................................................................................................................................................................................................................................................................................................................................................................................
■ Nee
Wijze waarop uitvaart moet plaatsvinden Plaats van opbaring ■ Thuis:....................................................................................................................................................................................................................................................................................................................................................................................... ■ Zorgcentrum / verpleeghuis:............................................................................................................................................................................................................................................................................................................. ■ Rouwcentrum:. ........................................................................................................................................................................................................................................................................................................................................................ ■ Elders, nl.:........................................................................................................................................................................................................................................................................................................................................................................
Verlenen laatste hulp door ■ Familieleden / vrienden ■ Personeel Zuidema
Kleding voor opbaring:............................................................................................................................................................................................................................................................................................................................................ ......................................................................................................................................................................................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................................................................................................................................
Gelegenheid om afscheid te nemen ■ Alleen voor naaste familie ■ Voor alle belangstellenden ■ Anders, nl.:....................................................................................................................................................................................................................................................................................................................................................................
Gelegenheid tot condoleren ■ De avond voor de plechtigheid ■ Na de plechtigheid ■ Beide
Consumpties ■ Koffie, thee en fris ■ Koekjes ■ Cake ■ Broodjes ■ Anders, nl:......................................................................................................................................................................................................................................................................................................................................................................
Uitvaart in besloten kring:
■ Ja
■ Nee
Kerkelijke uitvaart:
■ Ja
■ Nee
Locatie van de plechtigheid:.......................................................................................................................................................................................................................................................................................................................................... Spreekgelegenheid tijdens de plechtigheid: ■ Ja: namen sprekers: ........................................................................................................................................................................................................................................................................................................................................ ......................................................................................................................................................................................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................................................................................................................................
■ Nee
Muziekkeuze: Bij binnenkomst: ......................................................................................................................................................................................................................................................................................................................................................................................................................
Tijdens de plechtigheid: ......................................................................................................................................................................................................................................................................................................................................................................................................................
Bij het verlaten van de zaal: ......................................................................................................................................................................................................................................................................................................................................................................................................................
(Uiteraard zijn er meer dan drie muziekstukken mogelijk.) Foto presentatie tonen tijdens de plechtigheid
■ Ja
■ Nee
Geluidsopname gewenst: ■ Ja
■ CD
■ DVD
■ Nee Fotoreportage:
■ Ja
■ Nee
Video-opname:
■ Ja
■ Nee
Keuze gemaakt voor kisttype en -kleur: ■ Ja, nl.:...................................................................................................................................................................................................................................................................................................................................................................................... ■ Nee, deze keuze laat ik over aan de nabestaanden
......................................................................................................................................................................................................................................................................................................................................................................................................................
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Bloemstukken tijdens de uitvaart:
■ Ja
■ Nee
Indien ja, voorkeur voor bloemsoort en/of -kleur: ......................................................................................................................................................................................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................................................................................................................................
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Vervoer op dag van de uitvaart: ■ Rouwauto
■ Zwart
■ Grijs
■ Wit
■ Anders, nl.:.........................................................................................................................................................................................
■ Rouwkoets ■ Uitvaartbus ■ Anders, nl:
Begrafenis Plaats van begraven:.................................................................................................................................................................................................................................................................................................................................................. Naam begraafplaats: ............................................................................................................................................................................................................................................................................................................................................... Soort graf ■ Algemeen graf ■ Particulier graf of familiegraf ■ Grafkelder ■ Anders, nl:......................................................................................................................................................................................................................................................................................................................................................................
Wijze van dragen ■ Met rijdende baar ■ Op de schouders ■ Door familie en / of vrienden ■ Door dragers / draagsters Kist dalen:
■ Ja
■ Nee
Klokluiden:
■ Ja
■ Nee
Muziek op de begraafplaats:
■ Ja
■ Nee
Grafmonument op het graf:
■ Ja
■ Nee
■ Maaiveld
Indien ja: ■ Materiaalsoort:........................................................................................................................................................................................................................................................................................................................................................ ■ Gewenst opschrift:. .......................................................................................................................................................................................................................................................................................................................................... ......................................................................................................................................................................................................................................................................................................................................................................................................................
......................................................................................................................................................................................................................................................................................................................................................................................................................
■ Opschrift wordt door nabestaanden opgesteld
Crematie Naam crematorium:.................................................................................................................................................................................................................................................................................................................................................... Vestigingsplaats:................................................................................................................................................................................................................................................................................................................................................................
Kist dalen tijdens de plechtigheid:
Pacemaker:
■ Ja
■ Ja
■ Nee
■ Half
■ Nee
Asbestemming: ......................................................................................................................................................................................................................................................................................................................................................................................................................
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Overige belangrijke gegevens Donorcodicil opgemaakt ■ Ja, de papieren daarvoor draag ik bij mij. Onmiddellijk na mijn overlijden dienen de daarin genoemde instanties te worden ingelicht. ■ Nee Testament opgemaakt:
■ Ja
■ Nee
Indien ja:
Naam notaris:. .................................................................................................................................................................................................................................................................................................................
Plaats:............................................................................................................................................................................................................................................................................................................................................
Datum van opmaken testament:......................................................................................................................................................................................................................................................
Inlogcodes / wachtwoorden Wij begrijpen dat het gevoelig ligt om inlogcodes, wachtwoorden of pincodes op papier te zetten. Toch is het raadzaam om hierover na te denken. Belangrijk zijn de wachtwoorden van de telefoon, computer, internet, woonhuisbeveiliging, pincode van de bank etc. Zorg ervoor dat deze gegevens bekend zijn en deze niet in verkeerde handen vallen.
Stichting Uitvaartverzorging Zuidema De laatste jaren is er steeds meer behoefte gekomen om van tevoren schriftelijk vast te leggen hoe de uitvaart er zou moeten zien. Persoonlijk wensen kunnen dan beter worden gerealiseerd. Om invulling te geven aan deze behoefte is Stichting uitvaartverzorging Zuidema opgericht.
Aan de hand van uw opgave van uw persoonlijke wensen voor de uitvaart is het mogelijk om een indicatie te geven van de kosten. Hierover kunt u met ons vrijblijvend contact opnemen.
Als u dat wilt, kunt u de totale kosten van de uitvaart of een deel daarvan, reserveren bij de Stichting. Het totaal gereserveerde bedrag wordt dan te zijner tijd aangewend voor de uitvaart. Ook zou het kunnen zijn dat u, vanwege bijvoorbeeld uw leeftijd of gezondheid, niet meer in aanmerking komt voor een uitvaartverzekering. Het is dan toch mogelijk de kosten van de uitvaart bij onze stichting te reserveren.
Aan het gestorte bedrag zal jaarlijks een rentevergoeding worden toegevoegd, waarmee de algemene jaarlijkse prijsstijgingen gedekt kunnen worden.
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Kantoor
Oud-Cromstrijensedijk O.Z. 87b 3286 BM Klaaswaal
0186-571517
www.zuidemauitvaart.nl
[email protected]
Afscheidshuis Strijen Kerkstraat 78a 3291 AM Strijen
Uitvaartcentrum Zuidema Maasdamseweg 1c 3295 LC ’s-Gravendeel 078-6733582
Afscheidshuis De Eendracht Koninginneweg 23a 3284 KJ Zuid-Beijerland
