Application for cremation of
stillborn baby
Cremation 3
replacing Cremation 3
issued 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
Name of funeral director Telephone number
Part 2 Your details (the applicant)
Your full name
Address Telephone number
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
/ /
Regulation 20(1)(a) of the Cremation (England and Wales) Regulations 2008
10.17
South West Middlesex Crematorium
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 par ents 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
Please state whether it was the applicant’s own home, hospital etc.
Cremation 3 continued over the page ]
2
Part 4 continued
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 Applicant’s instructions for ashes
Local practices regarding ashes vary and your funeral director or cremation authority
will be able to advise you about these.
Please then tick the relevant box to confirm whether you have chosen Option 1, 2 or 3 below
for the ashes following this cremation, and provide further details in the relevant free text box.
If you choose Option 1 or 2 you may alter your choice, confirmed in writing with your signature,
before the cremation authority has made arrangements to implement your chosen option, so
please advise your funeral director or the crematorium as soon as possible if you change your
mind.
Option 1: Ashes to be scattered / interred / otherwise dealt with by the crematorium
Please give further details of your wishes here, from the options offered by the crematorium,
for instance where the ashes should be scattered / placed and when; and whether you wish
this to be witnessed.
Option 2: Ashes to be collected from the crematorium
Please give further details of your wishes here, such as who will collect the ashes (for instance
you and / or another family member, the funeral director, or another specified person); and by
which date, if known. The person collecting the ashes should bring a form of identification.
Cremation 3 continued over the page ]
3
/
/
Part 5 continued
Option 3: Ashes to be held awaiting your decision
Please give further details of your wishes here, for instance where and for how long the ashes
should be held awaiting your decision.
When you have later made a decision, please confirm this, in writing with your signature, to
your funeral director or crematorium.
Part 6 Recovery of ashes
Despite every effort being made to recover ashes following a cremation, on very rare
occasions (particularly with a cremation following an early pregnancy loss) there may be no
recoverable ashes. If you have any questions about this, please ask your funeral director or
crematorium.
Please tick the box below to confirm that you understand this and that you wish to proceed with
the cremation.
Part 7 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 Dated
Cremation 3
4
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome