Fill - Free fillable Cremation-form-4-medical-certificate Cremation 4: Medical certificate PDF form

Medical certificate

Cremation 4

replacing Form B

This form can only be completed by a registered medical practitioner.

Please complete this form in full, if a part does not apply enter ‘N/A’.

Part 1 Details of the deceased

Full name

Address

Occupation or last occupation if retired or not in work at the date of death

Where a past occupation of the deceased person may suggest that the death was due to industrial

disease, you should consider whether to refer the death to a coroner.

Part 2 The report on the deceased

1. What was the date and time of death of the deceased?

Date Time

/ /

2. Please give the address where the deceased died.

Address

Please state whether it was the residence of the deceased or a hotel, hospital, or nursing

home etc.

Their home

Hotel

Hospital Other (please specify)

Nursing home

Regulation 16(c)(i) of the Cremation (England and Wales) Regulations 2008

01.09

Part 2 continued

3. Are you a relative of the deceased?

Yes No

If Yes, please give the nature of your relationship.

4. Have you, so far as you are aw are, any pecuniary interest in the

death of the deceased?

Yes No

If Yes, please give details.

5. Were you the deceased’s usual medical practitioner?

Yes No

If Yes, please state for how long.

If No, please give details of your medical role in relation to the deceased.

6.

Please state for

how

long you attended the deceased during

their last illness?

7.

Please state the number

of

days

and hours

before the deceased’s

death

that you last saw them alive?

Days

Hours

8.

Please state the date and time that

you saw

the body

of

the deceased and the

examination t

hat

you made of

the

body.

Date Time

Examination

/ /

Cremation 4 continued over the page ]

2

Part 2 continued

9. From your medical notes, and the observations of yourself and others immediately before

and at the time of the deceased’s death, please describe the s ymptoms and other

conditions which led to your conclusions about the cause of death.

10. If the deceased died in a hospital at which they were an in-patient, has a

hospital post-mortem examination been made or supervised by a registered

medical practitioner of at least five years’ standing who is neither a relative

of the deceased nor a relative of yours or a partner or colleague in the same

practice or clinical team as you?

Yes No

If Yes, are the results of that examination known to you?

Yes No

Note: ‘Five years’ standing’ means a medical practitioner who has been

a fully registered person within the meaning of the Medical Act 1983 for at

least five years and, if paragraph 10 of Schedule 1 to the Medical Act 1983

(Amendment) Order 2002 (S.I. 2002/3135) has come into force, has held

a licence to practice for at least five years or since the coming into force of

that paragraph.

Cremation 4 continued over the page ]

3

Part 2 continued

11. Please give the cause of death

1. (a) Disease or condition directly leading to death (this does not mean the mode of dying, such as heart

failure, asphyxia, asthenia, etc.: it means the disease, injury, or complication which caused death)

(b) Other disease or condition, if any, leading to (a)

(c) Other disease or condition, if any, leading to (b)

2. Other significant conditions contributing to the death but not related to the disease or

condition causing it.

12. Did the deceased undergo any operation in the year before their death?

Yes No

If Yes, what was the date and nature of the operation and who performed it.

Date of operation Who performed it

/ /

Nature of operation

13. Do you have any reason to believe that the operation(s) shortened the life of

Yes No

the deceased?

If Yes, please give details.

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4

Part 2 continued

14. Please give the full name and address details of any person who nursed the deceased during their

last illness (Say whether professional nurse, relative, etc. If the illness was a long one, this question

should be an swered with reference to t he period of four weeks before the death.)

15. Were there any persons present at the moment of death?

Yes No

If Yes, please give the full name and address details of those persons and

whether you have spoken to them about the death.

16. If there were persons present at the moment of death, did those

persons have any concerns regarding the cause of death?

Yes No

If Yes, please give details

17. In view of your knowledge of the deceased’s habits and constitution do you

have any doubts whatever about the character of the disease or condition

which led to the death?

Yes No

18. Have you any reason to suspect that the death of the deceased was

Violent Yes

No

Unnatural Yes

No

19. Have you any reason at all to suppose a further examination of the

body is desirable?

Yes No

If you have answered Yes to questions 17, 18 or 19 please give details below:

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5

Part 2 continued

20. Has a coroner been informed about the death?

Yes No

If Yes, please state the outcome.

21. Has there been any discussion with a coroner’s office about the

death of the deceased?

Yes No

If Yes, please state the coroner’s office that was contacted and the

outcome of the discussions.

22. Have you given the certificate required for registration of death?

Yes No

If No, please give the full name and contact details of the medical

practitioner who has

Full name

Address Telephone number

23. Was any hazardous implant placed in the body (e.g. a pacemaker,

radioactive device or ‘Fixion’ intramedullary nailing system)?

Yes No

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, has it been removed? Yes No

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6

Part 3 Statement of truth

I certify that I am a registered medical practitioner.

I certify that the information I have given above is true and accurate to the best of my knowledge

and belief and that I know of no reasonable cause to suspect that the deceased died either a violent

or unnatural death or a sudden death of which the cause is unknown or in a place or circumstance

which requires an inquest in pursuance of any Act.

I am aware that it is an offence to wilfully make a false statement with a view to procuring the

cremation of any human remains.

Your full name

Address Telephone number

Registered qualifications

GMC reference number

Signed Dated

Once completed, this certificate must be handed or sent in a closed envelope by, or on behalf of, the

medical practitioner who signs it to the medical practitioner who is to give the confirmatory medical

certificate except in a case where question 10 is answered in the affirmative, in which case the

certificate must be so handed or sent to the medical referee at the cremation authority at which the

cremation is to take place.

/ /

Cremation 4

7

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