Cremation 3 introduced in 2009
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’.
Name of crematorium where cremation will take place:
SOUTH WEST MIDDLESEX CREMATORIUM
Name of funeral director
Your full name
In the case of a stillborn baby who has not been given a name, in place of the name
insert a description sufficient to identify the baby.
Full name of baby
Date of stillbirth
1. Are you a parent of the stillborn baby?
If No, please give the nature of your relationship and explain why you are making
2. Have both parents been informed of the proposed cremation?
If No, please give the name of the parent and the reason(s) why they have not been
3. Has a parent of the stillborn baby expressed any objection to the proposed cremation?
If Yes, please give details.
4. Please give the address where the baby was stillborn.
Please state whether it was the applicant’s own home, hospital etc.
5. Do you know or suspect that the baby was not stillborn?
6. Do you consider that there should be any further examination of the stillborn
If you have answered Yes to questions 5 or 6,
please give reasons below.
I apply for the stillborn baby 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 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