Application for cremation of stillborn baby

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’.

 

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 stillborn baby

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

Sex

Male Female

Date of stillbirth

Part 4: The application

1. Are you a parent of the stillborn baby?

  Yes No

If No, please give the nature of your relationship and explain why you are making the application.

2. Have both parents been informed of the proposed cremation?

  Yes No

If No, please give the name of the parent and the reason(s) why they have not been contacted.

3. Has a parent of the stillborn baby expressed any objection to the proposed cremation?

  Yes No

If Yes, please give details.

4. Please give the address where the baby was stillborn.

Address


Postcode

Please state whether it was the applicant’s own home, hospital etc.

5. Do you know or suspect that the baby was not stillborn?

  Yes No

6. Do you consider that there should be any further examination of the stillborn baby's remains?

  Yes No

If you have answered Yes to questions 5 or 6, please give reasons below.

Part 5: Statement of truth

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

Signed  
Date