Application for Cremation

Full name of Applicant *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Full Name of deceased *

First Name

Last Name

Last known Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you an executor of the deceased? *

Yes

No

Are you a relative of the deceased? *

Yes

No

Have all the near relatives of the deceased been informed of the proposed Cremation *

Yes

No

If the application is not made by the executor, is there an executor of the deceased? *

Yes

No

To the best of your knowledge and belief, has any near relative or executor of the deceased expressed any objection to the proposed Cremation? *

Yes

No

Date *

MM

DD

YYYY

Time *

Hour

Minute

Second

AM PM

Where did the Deceased die? *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

(tick any that apply) Do you know or have any reason to suspect that the death was due, directly or indirectly to

Violence

Poision

Privation or neglect

Illegal Operation

Do you know any reason to whatsoever for supporting that an examination of the body of the deceased may be desirable? *

Yes

No

Do you know or have any reason to suspect that the body of the deceased contains a cardiac pacemaker or other biomechanical aid? *

Yes

No

Name of the ordinary medical attendant of the deceased *

First Name

Last Name

Address of the ordinary medical attendant of the deceased *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Was the deceased a member of a religious denomination whose tenets require the burning of the body to be carried out as a religious rite elsewhere than in an approved crematorium? *

Yes

No

*

By ticking the checkbox I recognise this as my authorisation as if it was my signature

Date Signed *

MM

DD

YYYY

Witness name *

First Name

Last Name

Witness Signature *

By ticking the checkbox I recognise this as my authorisation as if it was my signature

Witness Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country