Kee. WE SRasiuls ° CLAIMS APPLICATION & DISCHARGE HOLLARD FUNERAL PLAN Hollard. [ ‘SECTION 1 I ‘VALIDATION AND CONFIRMATION ] i Hs Degoegy ESA he claimant on this polly conf that have (0) Read, (i) understand, (i) agree, (v/ and wil adhere to the requirements noted es Secion 1, which is outlined on the orginal faxed cover sheet subyntted tome by HOLLARD, wich sts the requirement ofthe cli, (ote tht se fst page ofthe oxi ot to be fned wih the clan form andrequted canes. Should ou not ore to ay ofthe noted os, pleas ght end ice the speed number. 9.7, "or ond sbi recon sed inthe presence fo Conmisoer of Oth) SECTION2 ‘CONTRACT INFORMATION ‘SCHEME NAME poucy numBer [TOUS (Sj 1 INFORMATION OF THE POLICY HOLDER SURNAME | ES FULLNAMES | DE BORO ionumerr | 611 COG IIb 1 ‘SECTIONS INFORMATION OF DECEASED / LATE SURNAME | ESA FuLLNAMEs | WAyis FrERN ANIA iDNumeeR | “| ODT SOS! OF] RESIDENTIAL ADDRESS OF LATE octal So PostaL ADDRESS OF Myvi e- PosTAL Cove | “1520 POSTAL CODE | WORK TELEPHONIC AND ELECTRONIC CONTACT HOME. INFORMATION eu EMAIL SECTIONS INFORMATION OF EMPLOYMENT PRIOR TO DEATH OF THEATE (NAME OF EMPLOYER/ SCHOOL rh = TELEPHONE NUMBER = ferry researc ae FAX NUMBER | "ADDRESS OF EMPLOYER/ SCHOOL | ‘SECTIONS: INFORMATION ON DEATH OF THE INSURED /LATE DATE OF DEATA | IL = OU ~QO20 cause oF oeara ee cx (Please give full details) t = INFORMATION OF FUNERAL PARLOUR THAT CONDUCTED THE FUNERAL NAWE OF FUNERAL PARLOUR] Week VictORN Cuwnetal S2tvic ADDRESS OF PARLOUR | Hoag Ave EfPing Western Cape CONTACT PERSON ATPARLOUR Nictoe PETERSEN ¢ Tetno. | 631 275) bare or Funeral | hot — OU ~2020)REE: We Szasig POLICY NUMBER SECTION6 INFORMATION OF CLAIMANT & [_ ‘SURNAME | EST I Fuunames | De@oean CONnetiA WNNILINE, INUMBER | 1LOOGONILOS> ce PosTAL ADDRESS OF RESIDENTIAL ADDRESS OF CLAIMANT Relves — claimant EMMY TNE POSTAL CODE | 15 30. POSTAL CODE ‘TELEPHONIC AND ELECTRONIC WORK cet OSL 3SU SI CONTACT INFORMATION Home |CQ1=4S OS EMAIL RELATIONTO LATE | quater I ‘OCCUPATION NAME OF EMPLOYER > fhe paiey contains «continuation option and YOU ARE THE REMAINING SPOUSE ON THE POLICY phe inate ifyou WOUDLNE TO CONTE WT THEBENEFTSOF MHS POLY. EASESHECT |_| yp YES OR NO and ONE OF OUR CONSULTANTS WILL CONTACT YOU. ‘SECTIONT I INFORMATION OF TRIBAL AUTHORITY NAME OF TRIBAL GRIEF / HEADMAN "ADORESS OF TRIBAL CHIEF / HEADMAN = TELEPHONE NUMBER OF TRIBAL CHIEF / HEADMAN ‘SECTIONS PAYMENT / ELECTRONIC TRANSER VALIDATION REQUEST NAME OF BANK | ASS A ‘ACCOUNT NUMBER | OGRA OS SiS. BRANCHNAME | E>eliville GAN GEL RANCH CODE Account iyee | C4HtE@ue Acc ACC HOLDER 1D NuMBER | (LOCH ODI LOST "ACC HOLDER TEL NUMBER 1 419 [_‘steNaTuRe oF BaNKcAcc HOLDER | €@Baz7 oat 16-0 BOZO) SECTION 9 CONSENT TO GAIN ACCESS TO, SHARE AND RECEIVE INFORMATION ] ‘ beeora 4 ESan the dma herety ely Hoard Life Asrnce Compa othe dst Baws teem ONS ESM Wy ‘and state that ll the information furnished by me are true and complete. "Grits et itis ater png meno be oe ade Seon, lard fe rane hs rca wth cn us mcr ay oberpores ced ‘Te tigurnt or restre compere tse cin nner dete std Fran ron eke ene ha rusian and trating tis reer beso anen toe yb an enh et ny pu epee heen hereby onsen he savin of pte uae erga eins nd mda cnn ron ener tos, 0, Thtlrriln peed mepes of cetn an ply maybe eis the uu of rt othe Trey reves sahara ay Medes ecto hsl ante eon eden or hand ce slg leo reese ny ct vs wordnet rg oetret ot es he aren tora ees ect ah Waren a ob scoot orcaed toc hed SIGNATURE OF CLAIMANT Raz I parE] [6-OU OAT} “WITNESS NAME AND SURNAME | CAAA\ ESR WITNESS 1D NUMBER | G [SOSSRIEOR ‘WITNESS WORK TEL NUMBER. WITNESS CELL NUMBER [C713 bt WiTNeSs SIGNATURE | _7RESYQUUC bate] [O-OY DOL)ane Rel S525 13 separ sours os Saruch OF HEME OFFA (a ") NOTICE OF DEATH /STILLBIRTH {Bin ora Rein AS41881 —o4 ee AG63F 876901 ove complttin an sid atte Doparinent tone ee uthorine funeral undertaker “The for to be come a ck i wih LOOK LETTERS. Peso 7s CORRECT box. vise eaes. ‘isto ar COMPULSORY income sptezions Srna may ce i enon fhe he informant (ate: Te rs fe crvaraker rust be ikea by to unceak A. PARTIULARS OF THE DEC! tnatrtone ATH nn cs rtemrmounnse rn introns Src anor ics, cae ih pera Paes Sar tart ro dacesned blo, ted vermeseowcrssoone (les own [2 smi apna tet Fi a nat frre 4 ‘them eis i | 1 | Seen cnet intmenranrnmaninte Dna prt = 10 conmam or pepe the decoased wes ct presente The deconted wes tonite though word of mouth SIE cee cnt fe trometer eg tem snot (pc agennntnanemans bam ot est enh = (ge lzl del 1 Prec gettin te eyecare 42 Prince of Deal seks 5 act Rapti som Hyun ee gee en “THor sir =rail | pS eeente meme Ca none Za e[sii isl Sposa HOB euro 5 some eT eae te ee Cises em feroacnaaaeectt rey et - ma i HH 16 ie Rein re ts Gaerane Peo Bays Tow Yi Creoty ofa ttoud “iL 162 Pree of Bit 48 Fesexn all dame, {Soectyom fe ane case comptes) rate 212) 18.uow eptnel essed ie LLITrrrrrirrirorrittit Eason | CW [Tama aa == == Sama Tecoma ei ae ae erro years ago? (area = “Winer scented ned en oct any. “Sakina obec 0 most a. comme” Jonald' Zeacodois KoPUFSSSSUHI3 18 Donald Wars.ane Oil Finjuiee bution cabins oF SOUTH FRICA omrncat (Cae 8 (OF DEATH / STILLBIRTH — Ti {Bens and Deaths ington Act St ot19821 Pons 7 at seer __ Rovoramrnmuamsnmte ene se fea Pt tte ee = gts SRE eeceeseenneeneer em Ios Stton os ra cro s (E secareov arent VEOEALPEACTINENPOFEBONA REE chaaiaiaiedanannoaanysmenactaet a greiner neat ‘recurs of tne eden Practisonr /rofecsona! Nurse whe toute Or 4, Saname Mime i 25 Foreeras immer (28 Name of Heaen Fact? Practice | GE € BELG eo 2a. euen bane. RE IWICl fel [eet Ce ron CA Pe POW WN Tat | revel ‘oe ee SLT ASB AAU) room! SSS) Fe a ey oon ance ao on cxvcon fale oa orf eorme 8 peed et emedng tS rama suet cinoma ie __essanes zidelylt} sere ¢ - IVART SAK X 2G 750 C. CERTIFICATE BY MEDICAL PRACTITIONER) FORENSIC PATHOLOGIST crates becion Cts be fies xkby Modal Pratloner or Foronae Pathologic wis consi renova ventana, saan oeungen tet cat tat andes eater ct gosta cnconduaes be ose we wrasse hen Seton A ae bye a5 ie crease eae At 700 hes, SBN 9998) eee of Seat os. 302 Uneane Ose of Pasimoter S2.Nome of Madoogarvoney "1, anu Rance ue of Doeeares |. tee ueciraigred, herety cont that | piasined the body of the deceeted named in socidn A Sead tis ductased, tome best of i cameras aaa ceee mere | tera tases ae maar streaermanesyanSeamnnte acetate _ 1 L e ‘Soratie 0 aory Ne Pas. frigee) 22. § 3 Sune 35. Resident Adee EDIT ERIN ICIAIP G2 | poset € siemens EEE) omen (OIbiG ae UE se. mepacanndiemy Keiramt | anton — L_esom —— |_land omen spenty rr erty Sa ai fhe oecetsed meter ine i Pabst y howled ar elt te and creck Ge ls ow ab uy ey eo eran fons bga sent os norggea alan SO oe Ato 198), bo oven fang ane a hast of 7092)* REF: WE ESBS NFS paaee38 ons Pages of REPUBLIC OF SOUTHAFRICA DEPARTMENT OF HOME AFFAIRS. a NOTICE OF DEATH / STILLBIRTH \ [pisns ane Deaths Regalo Aat st of 1992) Beenne Ts roe completed infu and submited alte Department of Home Ar By Fan eo SLACK INK sth BLOCK LETTERS, Pease mark wihiZ9 COM Ts | Ts fr oe re incomplete appicotions and apglicaions hat sr et leben oo Ase invalid. (ot: Hs grote derma, efor on te unter ewe he wee) E, PARTICULARS OF FUNERAL UNDERTAKER Feary ete curse unaralngeraker Tenders mat enor nets rae ected edt efomart.toroed Funeral last uchons Surman ay sath come sf rem tha As, Dinwmectoasowcr (SIE on Gah sonore SRR ES yd 6. SARS Rag, Na nce x aereree 0} ye tical AL ‘Dotalls of Funeral Undertaker oF Authorised Represantatve ia eee AlalielasisissISieis) 52. Sunane T 59. Foronamee 8 Dieta Saat rocoomnet EEN & oases FD) ame of person who collet the decease: 6 tory No. Paespont orga 9. Surname 62 Forenrnes rescore ZRUNS © oatesiened | ear lS! Gi el 'F. FOR OFFICIAL USE ONLY ‘HA {669 wae suomi by:WE SSBSNGYS ! ReF 2 318 8 i comes & Donald 's NOTICE OF DEATH / STILLBIRTH CConfimation fr osica ana Heath use Only “Te-bs completed in tut and subiifed ot re Ooperinent of Home Atle office by te infomiant or authorised Kunora! unitertaker. “Thi fou fo be comple n BLACK INK wth BLOCK LETTERS. Please mark wih Zhe Cc | altMelgs ave ComPuLs are not leg (ate: he frgereints ct j 1663) % ) rouwro Dpaweans | FOTO Page fort us J. wna et Tn i The DHA-1663 Notice of Death/Stilibirth is Confidential, This page can ONLY be opened by Statistics SA Officials. CONFIDENTIAL CONFIDENTIALITY. SEAL, DO NOT OPEN. TAMPERING WITH THIS FORM IS A BREACH OF “PareC887 Ties « Cespy Ko! WESEBS IG com 5 tone ¥ foe ed DHAMAA Rspupiie os ‘IC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS Annexure 16 BURIAL ORDER [Births and Deaths Registration Act 51 of 1992] [Regulation 16] ‘The form to be compieted in BLACK INK with BLOCK LETTERS. Please mark with Ml the CORRECT ‘box, where required by the HOME AFFAIRS OFFICIAL Date of Issue Bfobfe] fos! We Ser manor seeder roraess[ eT STH SHALL | A. PARTICULARS OF DECEASED vewemon — Belelet] GSLolsh) ele TAISA) fo} BI reer ruber pwvsn(POPIe] fo ul cuzerip (sh I s« Mor Suname ESD Previous or Maden enane Forenames Deel! corn” = FU Tele URE Province [ua] Sern (CI lel As eI Province sf Cause ot dean ata [7 Umnatret |] Under vestigation B. AUTHORITY FOR BURIAL OF CORPSE Tis certificate grants the authority for the burial ofthe corpse from the magisterial district in which the death occured or atthe magisterial istrict where the burial will ake place. C. FOR OFFICIAL USE ONLY Registration of death approved and burial order issued: DHA-1663 receive by (particular of DHA. MENT OF HOME AFFAIRS| ‘Sumame fT PRIVATE BAG X6 Foronanea TL qOPOANE amd HH 18 a PETES Lowenser west 7129 Seen eae Copyetbodensatsinpeat — eapeemretmemen DHA-1663 was submitted by: Tf omant =} Finerat Undertaker ‘entity Number of Recipient: Wontiy number [6 Lely [io| aT} 6 [gh {Funeral Undertaker: Designaton number [CPF] SIAL I Signature of recipiont { Pp Date received ero} [Ola] [fheKEP, WE SE3SYIZ t g G 8622858 ~ Deparment eyDHA-5 REPUBLIC oF souTH APRIGR OG ED A PARTEDEARG Fon GHEROPEL Ann héaStch lito: 390221. 505108 1 ESAU DAVID HERMANUS = 19392602721. MARRIED 2020-04-11 PAROW. NATURAL CAUSES DATE OF ISSUE: 2620-04-16 ASSURED BY: ¥ LL, PONOANE, Sat 22921796 225 Bh 46 SOMERSET WEST 7128 RSFREF : WE S828 WIS anid onda gueze “1 pleuog sHive - -oSiNWOS CET EA COPY OF BRIG rake commer™ Ans, On FagREF: WE S835 1412 AMIS seins a bate, ards toon nid Sa a re ‘ean se ee A AIRE Sa sz660e19 ; © ivaveweiinae RIKAANSE POLISIEDIENS D-AFRIKAANSE POLI eos |REP: WE SE3SIYIZ eStamp Ref 1871366650495614 CHEQUE ACCOUNT STATEMENT 2020/04/15 TERMINAL, : BELVILLE SANBEL 1 TERMINAL NUMBER: 09292 Se ee DATE 2020/04/15 TIME pais ‘02600 08600 and celect option S SEQUENCE NUMBER! CARD NUMBER: S#tEkasenneg3sg ‘Absa Bank Led MISS DLA ESAU UNIESTRAAT 3 BELLVILLE-suzD 7530 ACCOUNT NUMBER: 4062908812 STATEMENT FOR PERIOD 2020/04/01 - 2020/04/15 DATE TRANSACTION, REFERENCE BALANCE : BALANCE B/FORWARD 13,295.50+ Stop Card/Stopkeart 0800 11 11.55 (absa) strteams cece Sees SSS ar