Fillable Cremation-form-5-confirmatory-medical-certificate Cremation 5: Confirmatory medical certificate

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Cremation-form-5-confirmatory-medical-certificate Cremation 5: Confirmatory medical certificate

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Confirmatory medical certificate
Cremation 5
replacing Form C
This form may only be completed by a registered medical practitioner of at least five years’
standing who is not either a relative of the deceased, the medical practitioner who issued the
medical certificate (form Cremation 4) or a relative or a partner or colleague in the same practice
or clinical team as the medical practitioner who issued that certificate.
‘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.
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
Part 2 The report on the deceased
1. Have you questioned the medical practitioner who gave the Medical
Certificate ( form Cremation 4)?
Yes No
If No, please give reasons.
Regulation 16(c)(i) of the Cremation (England and Wales) Regulations 2008
01.09
Part 2 continued
In answer to questions 2, 3, 4, and 5, please give names and addresses of persons questioned
and say whether you spoke to them in person or by telephone. Any failure to answer one of these
questions in the affirmative may be treated as inadequate enquiry.
2. Have you questioned any other medical practitioner who attended t he
deceased?
Yes No
If Yes, please give the full name and address details of the medical practitioner(s).
3. Have you questioned any person who nursed the deceased during t heir last
illness, or who was present at the death?
Yes No
If Yes, please give the full name and address details.
4. Have you questioned any of the relatives of the deceased?
Yes No
If Yes, please give the full name and address details.
5. Have you questioned any other person?
Yes No
If Yes, please give the full name and address details.
Cremation 5 continued over the page ]
2
3
Part 2 continued
6. 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
7. Do you agree with the cause of death given in question 11 of Part 2 of the
Medical Certificate (form Cremation 4)?
Yes No
If No, please give reasons and give the cause of death.
Reason(s) for disagreeing
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.
Cremation 5 continued over the page ]
Part 3 Statement of truth
I certify that I am a registered medical practitioner of at least five years’ standing and I am not a
relative of the deceased, or a relative or a partner or colleague in the same practice or clinical team as
the medical practitioner who has given the Medical Certificate (form Cremation 4).
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 willfully 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 and the Medical Certificate (form Cremation 4) must be handed or
sent in a closed envelope by one of the medical practitioners giving the certificates to the medical
referee at the cremation authority at which the cremation is to take place.
/ /
Cremation 5
4
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Cremation-form-5-confirmatory-medical-certificate Cremation 5: Confirmatory medical certificate

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Completed 7 July 2020

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