Haven Funeral Services Ltd

Personal & Contact Details
Full Name:
Current Address:
Phone:
E-mail:
Date of Birth:
Place of Birth (town / country):
Occupation / Profession:
Parents Details
Fathers Full Name:
Fathers Occupation:
Mothers Full Name:
Mothers Maiden Name:
Mothers Occupation
First Marriage Details
To whom Married:
Age Married:
Place Married:
Second Marriage Details (if applicable)
To whom Married:
Age Married:
Place Married:
Details of Living Children
Dates of Birth of Males:
Dates of Birth of Females:
Returned Service Details (if applicable)
Service Number:
Rank:
Funeral Requests
Type of Service:	Burial	Cremation
Burial plot reserved at:
Please do the following with my ashes:
Special Song or Music:
Special Reading:
Donations to:
Other Requests: (eg preferred venue, officiant, flowers, type of casket etc)
Your Contact Person   (person responsible for carrying out your requests - eg next of kin or executor of will)
Contact Person Name:
Contact Person Address:
Contact Person Phone:
Follow up
Would you like us to contact you to discuss your wishes further	Yes    /    No