Lakelands Crematorium
|
|
|
- Gordon Russell
- 6 years ago
- Views:
Transcription
1 Form A Lakelands Crematorium FUERAL DIRECTOR COFIRMATOR ORDER FORM Dublin Rd, Cavan, Co. Cavan. Tel: Fax: info@lakelandscrematorium.ie Web: PLEASE TICK WHETHER FORM C OR FORM D TO FOLLOW Funeral Director... Telephone:... Address Age... Sex... Religion...Date of death... ame of Deceased... Married Address... Divorced Single Separated Widow/er Place of Death (if different from above)... Occupation... Cremation to take place: Day... Date... Time... Mode of disposal of cremated remains: (a) Private Disposal: Urn Casket Supplied Urn Interment in Columbarium wall B! ASHES OF DECEASED ARE ORMALL AVAILABLE FOR COLLECTIO 3/4 WORKIG DAS AFTER THE CREMATIO SERVICE (b) Memorial Option: State which option:... How many spaces (max 3):... Confirm inscription:... If the deceased has any of the below implants, these must be removed as they will damage the Cremator whilst Cremating. (a) Heart Pacemaker (b)heart Defribulator (c) Radio active implant (d)artificial arms or legs (e)fixion Implant (f)baclofen pump OTE: CREMATIO MA BE REFUSED IF A OF THE ABOVE IMPLATS ARE OT REMOVED o batteries, bottles, alcohol, electronic devices or glass permitted in the coffin as these will also damage the cremator whilst cremating. If the coffin is longer than 71/2ft, wider than 3ft or more than 2ft in height, please contact the crematorium to see if coffin is suitable for cremating. o cardboard coffins are accepted for cremation or coffins with pitch inside. I hereby certify that I have complied with all regulations laid down by Lakelands Crematorium Signature of Funeral Director... FORMS TO BE SCAED AD ED TO IFO@LAKELADSCREMATORIUM.IE AS SOO AS POSSIBLE
2 This form is issued by Lakelands Crematorium Dublin Rd, Cavan, Co. Cavan. Tel: Form B APPLICATIO FOR CREMATIO B EXECUTOR OR EAREST EXT OF KI ALL QUESTIOS MUST BE ASWERED PURSUAT TO THE BE LAWS MADE B LAKELADS CREMATORIUM This application should be made preferably by an executor and witnessed by a third party at bottom of this page. If not, then by the nearest surviving relative (SR). This application CAOT be made by a Common Law partner or a friend. (ame of Applicant)... Mr./Mrs./Miss ie ext of Kin or Executor (Address) (Occupation or Description)... apply to Lakelands Crematorium Company to undertake the cremation of the remains of:- (ame of Deceased)... First ame in full (Address)... (Occupation)... Age... Sex... Religion... Married Single Separated at LAKELADS CREMATORIUM. The answers must be completed by the applicant (Executor or SR only!). Divorced Widow/er on Are you an executor or the nearest surviving relative (SR) of the deceased?, Please state which. If you are the SR, please state your relationship to the deceased If answer to 1 is o. (a) our relationship to the deceased (a)... (b) The reasons why the application is made by you and not an executor or nearest surviving relative. (b) Has the nearest surviving relative of the Deceased been informed of the proposed cremation? 4. Do you know or have any reason to suspect that the death of the deceased was due directly or indirectly to (a) Violence or misadventure (b) Unfair means (c) egligence (d) Malpractice on the part of others (e) Poison / Alcohol / Drug related 5. Has the deceased been fitted with any artificial implant? Ises,Please state what form below and in form your funeral director as he/she has a list of implants that will damage the cremator on Form A of the Cremation Forms.... B! o batteries, bottles, alcohol, electronic devices or glass permitted in the coffin as these items will also damage the cremator whilst cremating. Any residual metals (i.e. coffin nails, body implants) following cremation are recycled. Monies received from this recycling programme are donated annually to St Christopher s Hospice. OTE: CREMATIO MA BE REFUSED IF A DAMAGIG IMPLAT IS OT REMOVED B! THE CREMATIO ASHES OF DECEASED MUST BE COLLECTED O LATER THA 1 MOTH AFTER THE CREMATIO SERVICE. I declare that to the best of my knowledge and belief the information given in this, is correct and no material in particular has been omitted. Date:... (Signature of Applicant) i.e. Executor or SR... The applicant is known to me and I have no reason to doubt the truth of any of the information furnished by the applicant. Date:... (Signature of Witness)... (Address)... Please Print ame... Date... This form when completed should be sent to the Secretary, Lakelands Crematorium Dublin Rd, Cavan, Co. Cavan. info@lakelandscrematorium.ie
3 This form is issued Lakelands Crematorium Dublin Rd, Cavan, Co. Cavan. Tel: Form C info@lakelandscrematorium.ie These Certificates are to be returned to the Funeral Director or Crematorium AS SOO AS POSSIBLE DEAR DOCTOR, PLEASE READ BELOW VER CAREFULL!!! Before you begin to answer this form, please note that you must fulfil all the criteria below first: (a) ou must have at least some knowledge of the deceased s medical history. (b) ou must have seen the deceased before death, within 4 weeks of death. (c) ou must have seen the deceased after death. (d) ou must be fully registered on the Medical Register of Ireland i.e. Post-Intern year (e) ou must report the death to your Coroner, if applicable. If you do not fulfil ALL of the above criteria, then STOP! ou cannot continue. Please contact the Funeral Director immediately FORM C MEDICAL CERTIFICATE I am informed that application is about to be made for the cremation of the remains of: (ame of Deceased)... (Address)... (Occupation of Deceased)... (Age)... HAVIG SEE AD IDETIFIED THE BOD BEFORE AD AFTER DEATH I give the following answers to the questions set out below:- 1. (a) Were you the regular attending doctor of the Deceased ) (a)... (b) If so, for how long? ) (b) (a) Did you attend the Deceased during his or her last illness ) (a)... (b) If so, for how long? ) (b) (a) When did you last see the Deceased alive? ) (Date)... (say how many days or hours before death) ) (Days or Hours) (a) How soon after death did you see the body? and ) (a)... (b) What examination did you make? ) (b) (a) On what date and at what hour did he or she die? ) Date... Hour (a) What was the place where the Deceased died? ) (a)... Give address and... (b) Say whether Deceased s own residence, lodging, hotel hospital, nursing home etc. ) (b) (a) Are you a relative of the Deceased? ) (a)... (b) If yes, state relationship ) (b) Have you, so far as you are aware, any financial interest in the death of the Deceased. )...
4 Form C. (COTIUED) 9. Cause of death and duration of last illness: O ABBREVIATIOS Approximate interval. I. I between onset and death Disease or condition (a)... directly leading to death due to (or as a consequence of) Antecedent causes (b)... Morbid conditions, if any, due to (or as a consequence of) giving rise to the above cause, stating the underlying condition last (c).... II Other significant conditions. II contributing to the death but... not related to the disease or condition causing it. OTE: IF DEATH IS OT DUE TO ATURAL CAUSES, (IE FALL, FRACTURE, ALCOHOL / DRUG RELATED) OU MUST REPORT THE DEATH TO OUR COROER 10. (a) State how far the answer to the last question is the result of your own observation.... (b) If not your own observation, what was the source of your information? (a) Have you or any other doctor performed an Autopsy on the body? ) (a)... (b) If es state by whom the examination was made. ) (b) By whom was the Deceased nursed during his or her last illness. )... (Give names and say whether professional nurse, relative etc. If the illness was a long one this question should be answered with reference to period of four weeks before the death). ) Who were the persons present (if any) at the moment of death. ) In view of your knowledge of the Deceased s habits and constitution, do you feel any doubt whatever as to the character of the disease or the cause of death stated in 9. above? )...
5 Form C. (COTIUED) 15. Have you any reason to suspect that the Deceased person died either directly or indirectly as a result of: (a) Violence or misadventure (a) es / o... (b) Unfair means (b) es / o... (c) egligence or misconduct (c) es / o... (d) Malpractice on the part of others (d) es / o... (e) Poison / Alcohol / Drug related (e) es / o... (f ) Falls / Fractures (f ) es / o... (g) Any other than natural illness (g) es / o... or disease for which he/she had been seen and treated by a registered medical practitioner within one month before his/her death: IF OU ARE I A DOUBT ABOUT A OF THE ABOVE ASWERS, PLEASE DISCUSS WITH OUR COROER. 16. Do you know or have you any reason to suspect that the death occurred under or within 24 hours of an anaesthetic or Medical Procedure (a) Have you any reason to suspect that the death of the Deceased should properly be reported to the Coroner? ) (a)... (b) If so have you or anybody else done so ) (b)... What was the outcome of the discussion Have you any reason whatever to suppose a further examination of the body to be desirable? ) (a) Did you sign the medical Certificate of the Cause of Death? ) (a)... (b) If not who has? ) (b) (1) Has the Deceased been fitted with? (a) A Cardiac Pacemaker / Defribulator ) (1.) (a)es / o... (b) A Radioactive Implant ). (b)es / o... (e) Other Prosthesis ). (e)es / o... (2) If the answer to any of the above is in the affirmative, has this implant been removed? ) (2.) es / o... OTE: CREMATIO MA BE REFUSED IF A ARTIFICIAL IMPLAT IS OT REMOVED AS THE WILL DAMAGE THE CREMATOR OUR COMPLETIO OF THIS FORM C WILL BE DEEMED VOID IF OU ARE OT FULL REGISTERED O THE MEDICAL REGISTER OF IRELAD I.E. POST ITER EAR I hereby certify that the answers given above are true and accurate to the best of my knowledge and belief. ame... (Signature)... (please insert name here in block capitals). Date:... Telephone o... (Address) Registered Qualification... ear & Month of Full Registration on The Medical Register of Ireland... (not provisional) Medical Registration o...
6 COROER S CERTIFICATE FOR CREMATIO Form D I Certify that:- I am satisfied that there are no circumstances likely to call for further examination of the body. PARTICULARS OF DECEASED PERSO Full ames... Sex... Age... Date of Death... Place of Death... (Please insert name here in block capitals)... Signature... Coroner for the of Date... If the deceased has any of the below implants, these must be removed as they will damage the Cremator whilst Cremating. (a) Heart Pacemaker (b)heart Defribulator (c) Radio active implant (d)artificial arms or legs (e) Fixion Implant (f) Baclofen pump OTE: CREMATIO MA BE REFUSED IF A ARTIFICIAL IMPLAT LISTED ABOVE IS OT REMOVED. OTE: This Certificate is issued for the purpose of cremation only and must be delivered to the Funeral Director or Lakelands Crematorium as soon as possible. The Cremation cannot be proceeded with unless this Certificate is so delivered. Lakelands Crematorium contact details: Dublin Rd, Cavan, Co. Cavan. Tel: info@lakelandscrematorium.ie
LIFE INSURANCE CLAIM
LIFE INSURANCE CLAIM Life Insurance Claim - Instructions 1. For a Life Insurance Claim: The beneficiary (claimant) should complete the Beneficiary s (claimant s) Statement and submit the completed claim
AUTHORIZATION FOR CREMATION, PROCESSING, AND DISPOSITION OF THE REMAINS OF SOCIAL SECURITY NO.
Barr-price funeral homes And Crematorium 609 Northwood Road, Lexington SC 29072 P: (803) 532-4411 F: (803) 532-0408 AUTHORIZATION FOR CREMATION, PROCESSING, AND DISPOSITION OF THE REMAINS OF SOCIAL SECURITY
INDIVIDUAL DEATH CLAIM FORM
INDIVIDUAL DEATH CLAIM FORM Dear claimant, We are sorry to learn about the death of our policyholder. In order for us to process your claim, we require the following: (1) Claimant s Statement (2) Consent
COAST CITIES CREMATIONS Phone: (805) Fax: (805) A Loma Vista Rd Hollister Avenue #E Ventura, CA Goleta, CA 93117
To whom it may concern, Attached are the necessary forms for completion and require signatures. Please complete and sign all documents next to the X or bold arrow. If you have any questions while completing
COMMONWEALTH OF KENTUCKY OFFICE OF THE ATTORNEY GENERAL CREMATION AUTHORIZATION FORM CR-1, #11-02
Date Cremation Received: Cremation Number: Date of Cremation: Name of person performing cremation: COMMONWEALTH OF KENTUCKY OFFICE OF THE ATTORNEY GENERAL CREMATION AUTHORIZATION FORM CR-1, #11-02 Woodlawn
DECEDENT/AUTHORIZING AGENT INFORMATION
101 E 7 th Avenue, Redfield, SD 57469 Phone: 605-472-2444 Fax: 605-472-2445 www.hykefuneralhome.com AUTHORITY TO CREMATE AND ORDER FOR DISPOSITION THIS IS A LEGAL DOCUMENT It Contains Important Provisions
A. L. HUGHES & CO. SOLICITORS & COMMISSIONERS FOR OATHS ESTABLISHED Wills Service. Guide for Clients
A. L. HUGHES & CO. SOLICITORS & COMMISSIONERS FOR OATHS ESTABLISHED 1950 Wills Service Guide for Clients And Instructions Questionnaire For completion and return Why is this Important? This leaflet has
SALARY LOAN ACCOUNT. 1. All salary loans Debtors of Land Bank should be covered by Credit Life Insurance (CLI).
SALARY LOAN ACCOUNT 1. All salary loans Debtors of Land Bank should be covered by Credit Life Insurance (CLI). 2. Credit Life Insurance (CLI) is an insurance against the life of the debtors to answer for
Name: Last Name First Middle Initial. Date of Birth: Age: Sex: SS#: DL#: Home Address: Cell #: Home#: Work#:
Name: Last Name First Middle Initial Date of Birth: Age: Sex: SS#: DL#: Home Address: Cell #: Home#: Work#: Email Address: @ Occupation: Work address: Nearest Relative Living with You: Phone#: (Or nearest
When Someone Dies. Practical help for family and friends. What do we do now?
When Someone Dies Practical help for family and friends What do we do now? SERVICES To learn more about the services of the Delta Hospice Society, visit our website at www.deltahospice.org 2 Table of Contents
Death notification and application for death benefits
Date of receipt: Death notification and application for death benefits Before completing this form, please read the accompanying notes. Please complete this form using black ink and BLOCK CAPITALS. Part
How to pay for a funeral
How to pay for a funeral Information for patients from the Patient Experience Team This leaflet provides advice to people who have just lost a family member or a friend, and who have concerns about how
* DO NOT PROCEED BEFORE READING* Who can Sign a Cremation Authorization?
* DO NOT PROCEED BEFORE READING* Who can Sign a Cremation Authorization? All legal next of kin are required to sign the accompanying Cremation Authorization. The legal next of kin would be one of the following,
If you do not have ability to scan the form with the data and signatures included, please fax to
To: Gold Coast Cremation From: Phone: : Fax: 951-667-1611 Date: Total Pages Being Submitted: This paperwork is regarding (Check one): Advance Planning Imminent Death Death Has Occurred My Loved One is
KLEIN VOLUNTEER FIRE DEPARTMENT SQUYRES ROAD, KLEIN TX Volunteer Application Station Number
Volunteer Member Application Routing Check Off Sheet (FOR DEPARTMENT COMPLETION) Station Officer reviews application, interviews candidate and removes and retains Station Contact Sheet (last page) Station
RESOLUTION NO CREMATION OR BURIAL OF INDIGENT COUNTY RESIDENTS
RESOLUTION NO. 2012-66 CREMATION OR BURIAL OF INDIGENT COUNTY RESIDENTS WHEREAS, the Kootenai County Board of Commissioners desires to adopt uniform procedures for the cremation or burial of indigent County
Carter Family Dentistry
Carter Family Dentistry General Dentistry Patient Information Patient Name: Date: Last First MI Occupation: Employer: Title/Pos. 1 Male 1 Female 1 Single 1 Married 1 Child 1 Other Spouse s Name Social
TD Insurance Instructions for completing the claim package for Life Insurance
The Life Insurance Claim Package contains two parts: Part A: Life Claim Form Part B: Attending Physician's Statement Proof of Death TD Insurance Instructions for completing the claim package for Life Insurance
Golden Charter Funeral Plans Key Features Document
What documents do you give me? You ll receive a membership pack, which includes a summary of your plan and a personal membership card for you to carry in your purse or wallet. Once all your payments have
Cremation and Dissolution Disposition Authorization
Cremation and Dissolution Disposition Authorization Page One of Three Notice: This is a legal document that contains important provisions concerning Cremation and Dissolution. Please read this entire document
Golden Charter Funeral Plans Key Features Document
Golden Charter Funeral Plans Key Features Document This document is designed to help you decide which funeral plan and payment option is best for you. It contains information about what s included or not
PROTECTING THE ONES YOU LOVE
PROTECTING THE ONES YOU LOVE We have created this useful questionnaire to help you to carefully consider what you would like to happen to the people you care about & all the things that matter most to
CREMATION AND DISPOSITION AUTHORIZATION
For Crematory Use Only No. Date: Time: CREMATION AND DISPOSITION AUTHIZATION The State of Missouri requires that this Authorization Form be completed and signed prior to the cremation. Please read it carefully
Life Claims Package IMPORTANT!
Life Claims Package IMPORTANT! We are pleased to provide you with this claims package. There are some important points we would like to bring to your attention, to ensure that your claim is processed as
HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION
HARBORSIDE COUNSELING SERVICES CLIENT REGISTRATION Thank you for choosing our office. In order to serve you properly, we will need the following information. PLEASE PRINT: Name: Date: (Parents/caregivers):
PO Box 549 Abbeville, SC PH: Fax: AUTHORIZATION FOR CREMATION, PROCESSING, AND DISPOSITION
PO Box 549 Abbeville, SC 29620 PH: 864-366-4027 Fax: 864-366-4028 AUTHORIZATION FOR CREMATION, PROCESSING, AND DISPOSITION The State of South Carolina requires that this Authorization Form be completed
Will Questionnaire (Individual)
Will Questionnaire (Individual) This questionnaire is designed to help us to find out the information we need to prepare your Will and to advise you in relation to the issues that are important to you.
PATIENT INFORMATION. Name: Date of Birth: Age: Last name First Middle I. Home Address: City: State/Zip: Home Phone: Cell Phone:
THE ELITE LASER VEIN CENTER MICHAEL F. RICHMAN, M.D.,F.A.C.S. Date: PATIENT INFORMATION Name: Date of Birth: Age: Last name First Middle I Soc. Sec. #: Driver License#: Home Address: City: State/Zip: Home
PROBATE/TRUST ADMINISTRATION QUESTIONNAIRE
L AW O F F I C E S O F P A T R I C K M C N A L L Y P H O N E ( 7 1 4 ) 988-6 3 7 0 F A X ( 8 7 7 ) 883-9 7 1 6 E - M A I L : P A T R I C K @ P M C N A L L Y L A W. C O M PROBATE/TRUST ADMINISTRATION QUESTIONNAIRE
Set Funeral Plan Application Form (Please complete each section below in BLOCK CAPITALS with a black or blue ball-point pen).
Set Funeral Plan Application Form (Please complete each section below in BLOCK CAPITALS with a black or blue ball-point pen). How to apply - For Set Plans only. Step 1 Always complete the details of the
EAST GEORGIA REGIONAL MEDICAL CENTER STATESBORO, GEORGIA APPLICATION FOR VOLUNTEER SERVICES
EAST GEORGIA REGIONAL MEDICAL CENTER STATESBORO, GEORGIA 30458 APPLICATION FOR VOLUNTEER SERVICES DATE Names: Last First Middle Initial Address: P.O. Box or Route Street City State Zip Code Telephone Number:
The Cremation Society of New England provides simple, basic cremation services.
Simple Cremation Plan The Cremation Society of New England provides simple, basic cremation services. What is Included? Our Simple Cremation Plan provide everything essential for a direct cremation: Basic
Social Security Benefits
The Funeral or Memorial Service In many respects, a funeral or memorial service is primarily for the living. It offers your friends and loved ones a time and place to show their love and respect. It is
Carroll County Nephrology, PC
Carroll County Nephrology, PC Phone: 770-832-0429 Fax: 770-838-9108 Maria J. Orig, M.D. FASN Bryan D. Quinn, M.D. WELCOME TO CARROLL COUNTY NEPHROLOGY **Please bring the completed enclosed paper work with
1 ORIGINAL WILL 1 DUPLICATE WILL
The Original MALAYSIAN LEGAL WILL KIT 1 ORIGINAL WILL 1 DUPLICATE WILL Both Wills to be identically filled in and executed in accordance with the instructions as stated in Pages 15 to 25 of this Instruction
Patient Information TO BE COMPLETED BY PARENT/GUARDIAN ACCIDENT INFORMATION. Date SSN/HIC/Patient ID # Patient Name
1 Date SSN/HIC/Patient ID # Patient Name Address PATIENT INFORMATION Best time/place to contact you? E-mail Sex M F Age Date of Birth Married Widowed Single Separated Divorced Minor Patient Employer/School
RE: Pension Application Member ID #: XXX-XX. Dear Participant,
2357 59 th Street St. Louis, MO 63110 (314) 644-2777 ext. 3 1-800-489-0228 Fax: (314) 645-6226 RE: Pension Application Member ID #: XXX-XX Dear Participant, Congratulations! Our office was recently notified
My LAST WILL AND FINAL ARRANGEMENTS
My LAST WILL AND FINAL ARRANGEMENTS Includes: Personal Record Guide Things to Consider Family s Checklist Final Arrangements Online Information 84345 0913 Don t leave your final wishes to chance my Last
GUIDELINES FOR FAMILIES ARRANGING A CREMATION
GUIDELINES FOR FAMILIES ARRANGING A CREMATION Wakapuaka Crematorium Atawhai Drive, Nelson Although most funerals are arranged through a Funeral Director some people may prefer to make their own arrangements.
A p l a n n i n g g u i d e f o r t h e e n d o f l i f e
Journey s End A planning guide for the end of life Journey s End A planning guide Table of Contents Personal Information... 1 Legal Information... 6 Professional Providers... 9 Financial Information...
Exmouth Office Mobile 24 Hours
The arranger is the person primarily making the definitive funeral arrangements for the deceased and could be the family representative, executor, next-of-kin, solicitor or agent of the deceased or, person
Do the right thing see your lawyer first
Do the right thing see your lawyer first The information in this guide has been published by the New Zealand Law Society. Our objective is to inform you of your legal rights, the law, and how lawyers can
Safeguarding Your Business from Cremation Liability T. Scott Gilligan & Mike Nicodemus
NFDA Live Webinar January 8, 2015 1-2 p.m. CT Page 1 Safeguarding Your Business from Cremation Liability T. Scott Gilligan Mike Nicodemus NFDA Live Webinar January 8, 2015 1-2 p.m. CT Webinar Agenda 1.
Golden Charter Funeral Plans Key Features Document
Golden Charter Funeral Plans Key Features Document This document is designed to help you decide which funeral plan and payment method is best for you. It also provides you with information about what is
2018 D.C//T/P/S/R V010218
Safe Hands Plans Limited, trading as Safe Hands Funeral Plans Registered office: 8 Peterson Road, Wakefield, West Yorkshire, WF1 4EB (Tel: 0800 917 7099) Company No: 08869875 TERMS & CONDITIONS (the Terms
WILLS & ESTATES. Tips and tools for First Nations clients
WILLS & ESTATES Tips and tools for First Nations clients Wills & Estates on Reserve Parliament of Canada (INAC) has exclusive jurisdiction in all matters to do with Indians and land reserves for Indians
TITLE: Ashburton District Council Cemeteries Bylaw The title of this bylaw is Ashburton District Council Cemeteries Bylaw 2017.
Bylaw CEMETERIES TITLE: Ashburton District Council Cemeteries Bylaw 2017 TEAM: Open Spaces RESPONSIBILITY: Open Spaces Manager DATE ADOPTED: 29 June 2017 COMMENCEMENT: 29 June 2017 NEXT REVIEW DUE: 29
DESIGNATION OF BENEFICIARY FORM FOR PRE-RETIREMENT DEATH BENEFITS ONLY
DESIGNATION OF BENEFICIARY FORM FOR PRE-RETIREMENT DEATH BENEFITS ONLY Please read these instructions before completing the form. Use this form to designate or change a beneficiary only for Pre-Retirement
8. BIRTH STATE/ FOREIGN COUNTRY 9. SOCIAL SECURITY NUMBER 10. EVER IN U.S. ARMED FORCES?
SACRED SPACE MEMORIAL ~ VITAL INFORMATION FORM (Required for non-medical portion of the Death Certificate) Please type or print as clearly as possible. All information will be transcribed onto the official
YOUR GROUP INSURANCE PLAN BENEFITS
YOUR GROUP INSURANCE PLAN BENEFITS FREELANCERS UNION, INC. CLASSES 0001, 0002, 0003, 0004, 0005, 0006, 0007, 0008, 0009 & 0010 OPTIONAL LIFE, VOLUNTARY LTD The enclosed certificate is intended to explain
221 Madison Ave Morristown, New Jersey (973) Fax (973) PATIENT INFORMATION. Mailing Address: City: State: Zip: Birth Date:
221 Madison Ave Morristown, New Jersey 07960 (973) 538 4444 Fax (973) 538 0420 PATIENT INFORMATION Marc A. Cohen, MD, FAAOS, FACS Diplomate American Board of Spinal Surgery Fellow American College of Spinal
APPLICATION FOR THE AUTHORIZATION OF THE CREMATION PROCESS AND INSTRUCTIONS FOR THE DISPOSITION OF. Name of Individual to be Cremated (Deceased)
APPLICATION FOR THE AUTHORIZATION OF THE CREMATION PROCESS AND INSTRUCTIONS FOR THE DISPOSITION OF Name of Individual to be Cremated (Deceased) / / / Date of Birth Date of Death Time of Death Age NOTICE:
Funeral Plan Key Features
Funeral Plan Key Features Central England Co-operative Funeral Plan - Key Features Key features summary This document is designed to help you decide which funeral plan and payment method is right for you
Personal accident claim form
The issue of this claim form does not imply an admission of liability by us. Only a fully completed and signed claim form can receive our further assessment and consideration. Index Sections 1, 2, 9 and
Patient Registration
Patient Registration Date: / / Patient s First Name: Last Name: MI: Street Address: City,State,Zip: Primary Phone #: Home / Work / Mobile (circle one) Secondary Phone #: Home / Work / Mobile (circle one)
End-of-Life Planning and Reference Guide
End-of-Life Planning and Reference Guide A Resource for Spouses, Family and Loved Ones Developed by: Office of Marriage, Family & Respect Life Catholic Diocese of Sioux Falls www.sfcatholic.org/respectlife
Part B CONTRACT OF EMPLOYMENT FOR SEAFARERS
Part B CONTRACT OF EMPLOYMENT FOR SEAFARERS This Contract is made between the OWNER, hereinafter referred to as the Employer, and the person referred to in Part A attached hereto, hereinafter referred
EQ TRAVEL CLAIM FORM
EQ TRAVEL CLAIM FORM Agency Policy No Please note: Sections 1, 2 and 12 must be completed. Sections 3 to 11 complete only the relevant sections. The acceptance of this form is NOT an admission of liability
SECTION 1 (To be completed by the Life Assured who is at least 18 years old or the Policyowner if the Life Assured is below 18 years old)
C041017 TERMINAL ILLNESS CLAIM FORM PruCustomer Line: 1800-333 0 3333 Important tes 1. Please note that, under the policy terms and conditions, the policy may be void if any information provided in this
GROUP TOTAL & PERMANENT DISABILITY CLAIM FORM
Dear insured employee, GROUP TOTAL & PERMANENT DISABILITY CLAIM FORM We are sorry to learn about your illness/accident. In order for us to process your claim, we require the following: (1) Group Total
PERSONAL ACCIDENT OR SICKNESS CLAIM FORM
PERSONAL ACCIDENT OR SICKNESS CLAIM FORM This form must be completed truthfully and accurately. The list of documents required is not exhaustive and we reserve our right to request from you any additional
5. Attach a copy of your most recent Payslip to your claim submission. 6. Scan and the claim form through to
Personal Accident & Sickness Claim Form EMAIL: LIBERTY@FULLERTONHEALTHCS.COM.AU PHONE: +61 2 8256 1770 FAx: +61 2 8256 1775 LEvEL 10 33 YORK STREET SYDNEY NSW 2000 INSTRUCTIONS 1. You fully complete Sections
Beazley Group Personal Accident Insurance. form. claim. Page 1 of 9
Beazley Group Personal Accident Insurance claim form Page 1 of 9 Personal Accident Insurance Claim Form IMPORTANT INFORMATION We act upon your claim as soon as we receive this form. You can help us in
INSTRUCTIONS Wills, Powers of Attorney and Advanced Health Directive
INSTRUCTIONS Wills, Powers of Attorney and Advanced Health Directive Date: Next appointment: For further information see file: Documents to be prepared Will Power of Attorney (POA) Advanced Health Directive
Home Office: Schaumburg, Illinois Administrative Office: Philadelphia, Pennsylvania
Home Office: Schaumburg, Illinois Administrative Office: Philadelphia, Pennsylvania POLICYHOLDER: Sedgwick County Area Educational Services POLICY NUMBER: GL 154255 EFFECTIVE DATE: September 1, 2015, as
CHECKLIST OF DOCUMENTS REQUIRED. DOCUMENTATION SHOWING YOUR TRAVEL DATES AND FULL COST OF THE TRIP (booking invoice)
PA PERSONAL ACCIDENT Dear Customer, Travel Claims Facilities PO Box 395 Monks Green Farm Mangrove Lane Hertford SG13 9JW Email: claims@tif-plc.co.uk Web: www.tifgroup.co.uk In order that we can process
Funeral Plan Application Form
Funeral Plan Application Form Plan number: Please confirm whether the plan is for: Yourself Someone else Joint plan (You and one named other) Please confirm whether you wish to purchase: Set funeral plan
PROPOSAL FORM FOR LOSS OF FLYING LICENCE
PROPOSAL FORM FOR LOSS OF FLYING LICENCE Your attention is drawn to the declaration at the foot of this form. It is important for renewal or for an amount additional to an existing insurance. You should
ESTATE PLANNING QUESTIONNAIRE
The purpose of this questionnaire is: ESTATE PLANNING QUESTIONNAIRE 1. To help you organize personal and financial information so that you can assess your current estate plans and evaluate whether changes
ALABAMA STATE BAR WILLS FOR HEROES PROGRAM
ALABAMA STATE BAR WILLS FOR HEROES PROGRAM In order to make the Wills for Heroes project as convenient as possible we will be holding the program on site. For the process to run smoothly and take as little
Claim for. Death Benefits
Notice to readers: This document complies with Québec government standard S G Q R I 0 0 8-0 2 on the accessibility of downloadable documents. If you experience difficulties, please contact us at: 1 800
inheritance options the flexible approach to inheritance tax planning
inheritance options the flexible approach to inheritance tax planning more options for your future 055 About us Founded in 1939, we have been taking care of our customers' financial futures for over 60
LINE-OF-DUTY DISABILITY APPLICATION
CLAIMANT NAME SSN ] THE CITY OF BALTIMORE EMPLOYEES' AND ELECTED OFFICIALS' RETIREMENT SYSTEMS 7 East Redwood Street -- 13th Floor Baltimore, Maryland 21202-3470 Phone 443-984-3200 LINE-OF-DUTY DISABILITY
YOUR PLAN DETAILS AND APPLICATION FORM.
THE DIGNITY PREPAID FUNERAL PLAN YOUR PLAN DETAILS AND APPLICATION FORM. CHOICE OF 3 PLANS Legal & General working in association with: 2 YOUR APPLICATION FORM THREE LEVELS OF COVER AVAILABLE. There are
HAROLD GOODMAN, D.O SECOND AVENUE SUITE 405B SILVER SPRING, MD Patient Information
Patient Information Name birth date Address (street) apt. # (town, state, zip) Telephone: home cell phone Guardian (if a minor) work e-mail relationship Address (if different) telephone Employer Occupation
PERMANENT DISABILITY CLAIM FORM - DPS Policy - DPS and GEL Policy
PERMANENT DISABILITY CLAIM FORM - DPS Policy - DPS and GEL Policy Dear Claimant, We are sorry to learn of your disability. In order for us to process the Permanent Disability Claim, we require the following:-
Direct Cremation Plan
Direct Cremation Plan Services of Funeral Director and Staff Transfer of Remains to Our Facility Refrigeration Cremation Container - See Reverse Side for Options Crematory Fee Basic Temporary Urn Website
CREEKSIDE DENTAL REGISTRATION FORM. Please Print PATIENT INFORMATION. Patient s Last Name: First: Middle:
Today s date CREEKSIDE DENTAL REGISTRATION FORM Please Print PATIENT INFORMATION Patient s Last Name: First: Middle: Home Phone #: Work #: Cell #: Email Address: Street Address: City: State: Zip Code:
NEW LIFE COMMUNITY MIDWIFERY NOTICE OF PRIVACY PRACTICES Effective 1/1/2006
NEW LIFE COMMUNITY MIDWIFERY NOTICE OF PRIVACY PRACTICES Effective 1/1/2006 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Terms and conditions. Contents. Welcome to Co-op Funeralcare
Terms and conditions Contents 01 Welcome to Co-op Funeralcare 02 Who can buy a plan? 02 How does my plan work? 02 What s included in my plan? 02 What s not included in my plan? 04 How do I pay for my plan?
REDWOOD HILL ADULT FAMILY HOME Application for Residency and Emergency Information Form
REDWOOD HILL ADULT FAMILY HOME Application for Residency and Emergency Information Form 27229 45 th Pl South Kent, WA 98032 Tel (253) 981-3688 / Fax (253) 981-3586 Email: info@redwoodhillafh.com www.redwoodhillafh.com
Final Affairs Guide. Address: City: State: Zip: Table of Contents
Final Affairs Guide The purpose of this workbook is to help you organize your personal and legal information. After completion, please keep it in a safe place where it will be easily accessible to you
WHAT HAPPENS IF I DIE WITHOUT MAKING ANY WILL?
Making a Will WHAT HAPPENS IF I DIE WITHOUT MAKING ANY WILL? If you die without making a Will, the law provides that your spouse is entitled to your entire estate if there are no children. If you leave
Employer/Doctor Employer s Name Address: Referring Doctor Phone Number Primary Doctor Phone # Patient Information
FINANCE INSURANCE ORTHOPEDIC SPINE AND SPORTS MEDICINE CENTER 2 FOREST AVEPARAMUS, NJ 07652 PATIENT QUESTIONAIRE Patient s Name: Last First (legal): Middle Initial: Address: City: State: Zip: Date of Birth:
CONSUMER INFORMATION GUIDE TO FUNERALS, BURIALS & CREMATION SERVICES
CONSUMER INFORMATION GUIDE TO FUNERALS, BURIALS & CREMATION SERVICES LOSING A LOVED ONE CAN BE A DIFFICULT AND STRESSFUL TIME. Whether you need to arrange a funeral, burial or cremation service now, or
YOUR GROUP INSURANCE PLAN BENEFITS
YOUR GROUP INSURANCE PLAN BENEFITS INSURANCE COMMITTEE OF THE ASSESSORS INSURANCE FUND DBA LOUISIANA ASSESSORS ASSOCIATION CLASS 0001 - ALL ELIGIBLE ASSESSORS AD&D, DEPENDENT LIFE, LIFE The enclosed certificate
Consumer Information Guide to Funerals, Burials
Consumer Information Guide to Funerals, Burials And Cremation ServICes Losing a loved one can be a difficult and stressful time. Whether you need to arrange a funeral, burial or cremation service now,
Letter of Instructions for a New Retail Sales Outlet (Casket Store)
South Carolina Department of Labor, Licensing and Regulation South Carolina Funeral Service Board P.O. Box 11329 Columbia, SC 29211 Phone: 803-896-4497 Fax: 803-896-4554 www.llronline.com/pol/funeral Letter
Revised Feb Initials /
Policies and Procedures The Parish has undertaken the construction of the Columbarium to provide a reverential place to inter cremated remains in perpetuity in a memorial garden setting adjacent to the
NEW APOSTOLIC CHURCH BURIAL FUND
NEW APOSTOLIC CHURCH BURIAL FUND FAQ s FREQUENTLY ASKED QUESTIONS Q: What happens to young children if both parents, who are members of the Fund, die simultaneously? A: The children will be made beneficiaries
Part A CONTRACT OF EMPLOYMENT FOR SEAFARERS
Part A CONTRACT OF EMPLOYMENT FOR SEAFARERS This Contract is entered into between the Employee and the Employer and is based on the ITF Collective Bargaining Agreement No. F2474 dated 01 January 2012 The
Beneficiary Designation and Spousal Consent Form
Beneficiary Designation and Spousal Consent Form Lockheed Martin Corporation Salaried Savings Plan Qualified Pre-Retirement Survivor Notice This notice explains certain rights you have with respect to
425 North Wendover Road Charlotte, NC Birthdate: Social Security #: Male Female
425 North Wendover Road Charlotte, NC 28211 PATIENT INFORMATION: Patient s Legal Name: Nickname: Birthdate: Social Security #: Male Female Status: Minor (under 18) Single Married Separated Divorced Widowed
NOTICE OF PRIVACY PRACTICES
NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT COVERED PERSONS MAY BE USED AND DISCLOSED AND HOW COVERED PERSONS CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Table of Contents I. Life Insurance Basics 3 A. Insurable Interest... 3 B. Personal Uses of Life Insurance... 3 Survivor Protection... 3 Liquidity...
Table of Contents I. Life Insurance Basics 3 A. Insurable Interest... 3 B. Personal Uses of Life Insurance... 3 Survivor Protection... 3 Liquidity... 3 C. Determining Amount of Personal Life Insurance...
Funeral, Burial, Cremation & Transfer Services
CONSUMER INFORMATION GUIDE Funeral, Burial, Cremation & Transfer Services thebao.ca Losing a loved one can be a difficult and stressful time. Whether you need to arrange a funeral, burial, cremation or
AVIATION PERSONAL ACCIDENT INSURANCE
AVIATION PERSONAL ACCIDENT INSURANCE (AIR TRAVEL ONLY) CAPITAL SUM INSURED: each Insured Person In the event of an Accident involving more than one Insured Person travelling in the same Aircraft Insurers
Funeral Plan Terms & Conditions
Terms and Conditions as at July 2016 Funeral Plan Terms & Conditions 1. Eligibility Paying in full with a single payment or by Fixed Monthly Instalments by Direct Debit The Plan Purchaser is eligible for
your full legal name social security number / / occupation home address home phone # work phone # cell phone #
Individual trust Please print your entries clearly and legibly. Fill this workbook out in its entirety to the best of your ability. If you need more space, use another sheet of paper and attach it. a.
The Independent Way Funeral Plan Terms and Conditions TCS
The Independent Way Funeral Plan Terms and Conditions TCS 163-0617 INDEX Section 1 Section 2 Key Features of your Funeral Plan and Payment Options Applies only where you have chosen the Single Payment