Cremation Regulations 1954 - Form 6 (Page 2 of 2) in pdf

Cremation Regulations 1954 - Form 6 Page 2

Details of death

Date

/20

Time

a.m./p.m.

Place where deceased died

Home

Address

Hospital

Address

Other

Address

Do you know, or have reason to suspect, that the deceased’s death was directly or

indirectly due to any of the following? (tick if yes)

violence

drowning

poison

suffocation

privation or neglect

burns

medical procedure

Do you have any reason to suppose that an examination of the deceased’s remains may

be desirable?

Yes. Give details

Other applications

Have you, or anyone else that you know of, previously applied for a permit to cremate the

deceased’s remains?

Yes. Give details of previous application

Made by

Date

/ 20

Medical Referee to whom it was made

Signature of applicant

Signature

Date

/20

Statutory declaration

I, [name, address and occupation of person making the declaration]

(This section not to be

sincerely declare as follows –

completed by

That I make this application instead of an administrator because [give reasons]

administrator)

This declaration is true and I know that is an offence to make a declaration knowing that

it is false in a material particular.

This declaration is made under the Oaths, Affidavits and Statutory Declarations Act 2005

at [place

] on [date

] by

[Signature of person making the declaration]

in the presence of [Signature of witness authorised under the Oaths, Affidavits and

Statutory Declarations Act 2005]

[Name of authorised witness and qualifications as such a witness]

Medical referee

Permit No.

(For office use only)

Date

/ 20

Medical Referee

Signature

Name

*The nearest surviving relative of a deceased person is the first person who is available from the following persons

in the order of priority listed —

(a)

a person who, immediately before the death, was living as —

(i)

the spouse of the deceased; or

(ii)

a de facto partner of the deceased and who is at least 18 years of age;

(b)

a person who, immediately before the death, was the spouse of the deceased;

(c)

a son or daughter of the deceased who is at least 18 years of age;

(d)

a parent of the deceased;

(e)

a brother or sister of the deceased who is at least 18 years of age.

Cremation Regulations 1954 - Form 6 Page 2

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