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
/ /
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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.
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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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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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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.
/ /
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