Application for cremation of the body of a person who has died

Regulation 16(1)(a) of the Cremation (England and Wales) Regulations 2008

Cremation 1 - replacing Form A

This form can only be completed by a person who is at least 16 years of age. Please complete this form in full, if a part does not apply enter ‘N/A’.

 

Part 1: Details of the crematorium

Name of crematorium where cremation will take place:
SOUTH WEST MIDDLESEX CREMATORIUM

Name of funeral director

Telephone number

Part 2: Your details (the applicant)

Your full name

Address


Telephone number

Postcode

Part 3: Details of the person who has died

Full name

Address


Postcode

Occupation or last occupation if retired, or not working at date of death

Age at date of death

Sex

Male Female

Status

Married / Civil partnership
Widow / Widower / Surviving civil partner
Single

Part 4: The application

1. Are you a near relative or an executor of the person who has died?

  Yes No

Near relative means the widow, widower or surviving civil partner of the person who has died, or a parent or child of the person who has died, or any other relative usually residing with the person who has died, or a parent of a stillborn baby.

If No, please give the nature of your relationship and explain why you are making the application rather than a near relative or an executor.

2. Is there any near relative(s) or executor(s) who has not been informed of the proposed cremation?

  Yes No

If Yes, please give the name(s) and the reason(s) why they have not been contacted.

3. Has any near relative or executor expressed any objection to the proposed cremation?

  Yes No

If Yes, please give details.

4. What was the date and time of the death of the person who has died?

Date

Time

5. Please give the address where the person died.

Address


Postcode

Please state whether it was the residence of the person who has died or a hotel, hospital or nursing home etc.

Their home
Hospital
Hotel
Nursing home
Other (please specify)

6. Do you know or suspect that the death of the person who has died was violent or unnatural?

  Yes No

7. Do you consider that there should be any further examination of the remains of the person who has died?

  Yes No

If you have answered Yes to questions 6 or 7, please give reasons below.

8. What is the name, address and telephone number of the usual doctor of the person who has died?

(1) Doctor's name

Address


Postcode

Telephone

 

9. Please give the name, address and telephone number of the doctor(s) who attended the person who has died during their last illness.

(1) Doctor's name

Address


Postcode

Telephone

(2) Doctor's name

Address


Postcode

Telephone

10. Was any implant placed in the body which may become hazardous when the body is cremated (e.g. a pacemaker, radioactive device or “Fixion” intramedullary nailing system)?

  Yes No Don't know

Implants may damage cremation equipment if not removed from the body of the deceased before cremation and some radioactive treatments may endanger the health of crematorium staff.

If Yes, please give details and state whether it has been removed.

Part 5: Inspection of certificates

You are entitled to inspect the certificates (if any) given by doctors under regulation 16[c][i] of the Cremation Regulations 2008 (forms Cremation 4 and Cremation 5). If you do not wish to inspect any such certificates yourself you may nominate another person to inspect them instead of you. Such certificates will only be available for inspection for 48 hours from the time that the cremation authority notifies you, or the person you have nominated, that the certificates are available to be inspected. You may take someone with you when you attend to inspect the certificates. If you, or the person nominated by you, do not attend to inspect the certificates at the time agreed with the cremation authority, the cremation may then proceed. Please state if you would like to inspect the certificates given by the doctors or whether you would like to nominate someone else to do so instead and give a contact telephone number.

If certificates are given by medical practitioners :-

I would like to inspect the certificates and my contact telephone number is

I nominate to inspect the certificates and their contact telephone number is

Part 6: Statement of truth

I apply for the body of the person who has died to be cremated and I certify that I am at least 16 years of age. I believe that the facts given in this application are true. I am aware that is an offence to wilfully make a false statement with a view to obtaining the cremation of any human remains.

Print your full name

Signed
Date