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Personal information of person requesting service

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Personal information of person requesting service

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									          Personal information of person requesting service
Surname
Full name
Preferred name
ID Number
Physical address


Postal code
Postal address


Postal code
Telephone number
Cellphone number
Fax number
Email address
Occupation



                              Living will Self
        On my deathbed or soon afterwards my wishes are the following:
                                                         Yes           No
Turn off life supporting equipment when seriously ill
Do you want to donate your organs after death
Cremate body after death



                            Living will Spouse
        On my deathbed or soon afterwards my wishes are the following:
                                                         Yes           No
Turn off life supporting equipment when seriously ill
Do you want to donate your organs after death
Cremate body after death

								
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