Patient Decree - Hospiz im Park

6My Patient DecreePlease complete in fullPersonal information:Surname, first name: ..........................................................................................................Date of birth: ...........……….................................................................................................Street: .……….....................................................................................................................Postcode, town: ..................................................................................................................Telephone number: ............................................................................................................Proxy / Trusted third party 1 Proxy / Trusted third party 2Surname, first name: .......................................... Surname, first name: ...........................Street: .......................................................……… Street: ..................................................Postcode, town: .................................................. Postcode, town: ...................................Telephone: ......................................................... Telephone: ..........................................Mobile phone: .............................................… …. Mobile phone: ..................................…Email address: ...........................................…….. Email address: .....................................Family doctorSpiritual adviserSurname, first name: ..................................…… Surname, first name: ...........................Street: .......................................................…….. Street: ..................................................Postcode, town: ................................................. Postcode, town: ...................................Telephone: ......................................................... Telephone: ..................................…….Email address: ................................................... Email address: .....................................Form of burial desired............................................................................Date of issue: ..................................................... Signature: ............................................Date of confirmation: .......................................... Signature: ............................................Date of confirmation: .......................................... Signature: ............................................Date of confirmation: .......................................... Signature: ............................................