Application for cremation of body parts

Cremation 2 - replacing Form AA

Body parts means material consisting of, or including, human cells from a deceased person or stillborn baby.

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’.

If your application is about a stillborn baby, replace the words ‘person who has died’ throughout this form with the words ‘stillborn baby’.

 

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

In the case of a stillborn baby who has not been given a name, in place of the name and address insert a description sufficient to identify the baby.

Full name

Address


Postcode

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 place of the death or stillbirth?

Date

Address


Postcode

5. Please give the name and address of the cemetery, churchyard or crematorium where the body of the person who has died was buried or cremated.

Name of cemetery, churchyard or crematorium

Address


Postcode

6. Please give the date that the burial or cremation took place.

Date

7. Please state whether the body parts were removed from the body of the person who has died at a:

Coroner's post-mortem examination
Hospital post-mortem examination
Other (please specify)

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

  Yes No

If Yes, please give reasons below.

Part 5: Statement of truth

I apply for the following body parts of the person who has died to be cremated and I certify that I am at least 16 years of age.

Specify body parts to be cremated.

I believe that the facts given in this application are true. I am aware that it 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