Sender .       (* required fields)

E-mail sender*

Mr / Mrs *
please choose Mr. Mrs. Company

Name *

First name *

Company name

City - location - postal code *

Country *

Address - street - no.

Date of birth

Phone - Fax

Your relation to deceased

Place of death.

Name hospital etc. *

City - location - postal code *

Address - street - no.

Other place of death
at which location is the deceased now?

Name - location - etc. *

City - location - postal code *

Address - street - no.

Cause of death *
please choose natural death accident unknown

If it was not a natural death
reponsible police department.

Name - location - etc

City - location - postal code

Address - street - no.

Phone

Reference Number

Transfer to?

Country *

City - location *

Name and adress of th cemetery or
name and address place of delivery e.g. funeral home.

Cemetery - place to deliver - funeral director *

City - location - postal code *

Address - street - no.

Phone

Fax

E-mail

Contact person

Information of the deceased.

Mr.  / Mrs. *
please choose Mr. Mrs.

Name *

First name *

Birth name *

Date of birth *

Place of birth *

Family status *
please choose family status single married widowed divorced

City - location - postal code *

Address - street - no. *

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We will send to you a first specification of the expected expense.
The communicated information become extinguished, if you won´t place an order .