Fill - Free fillable Form 1 Application For Cremation (Borough Council of King's Lynn and West Norfolk) PDF form

Application for cremation of the body

of a person who has died

Cremation 1

replacing Cremation 1

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 person who has died

Full name

Address

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

Regulation 16(1)(a) of the Cremation (England and Wales) Regulations 2008

10.17

Email

Age at date of death Sex

Part 3 continued

Male Female

Status

married/civil partnership widow/widower/surviving civil partner Single

Part 4 The application

1. Are you a near relative or an executor of the person who has died?

Near relative means the widow, widower or surviving civil partner of the person

who has died, or a parent or child of the person who has died, or any other relative

usually residing with the person who has died.

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

making the application rather than a near relative or an executor.

Yes No

2. Is there any near relative(s) or executor(s) who has not been informed of the

proposed cremation?

Yes No

If Yes, please give the name(s) and t he reason(s) why they have not been contacted.

3. Has any near relative or executor expressed any objection to the

proposed cremation?

Yes No

If Yes, please give details.

4. What was the date and time of death of the person who has died?

Date Time

/ /

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2

Part 4 continued

5. Please give the address where the person died.

Address

Please state whether it was the residence of the person who has died or a hotel, hospital, or

nursing home etc.

Their home Hospital Other (please specify)

Hotel Nursing home

6.

Do you know

or

suspect

that

the death of

the person who has

died was

violent or unnatural?

Yes No

7. Do you consider that there should be any further examination of the remains

of the person who has died?

Yes No

If you have answered Yes to questions 6 or 7, please give reasons below.

8. What is the name, address and telephone number of the usual doctor of the person who has died?

Doctor’s name

Address Telephone number

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3

Part 4 continued

9. Please give the name, address and telephone number of the doctor(s) who attended the person who

has died during their last illness.

Doctor’s name

Address Telephone number

Doctor’s name

Address Telephone number

10. Was any implant placed in the body which may become hazardous when

Yes No

I don’t know

the body is cremated (e.g. a pacemaker, radioactive device, battery

powered device or “Fixion” intramedullary nailing system)?

Implants may damage cremation equipment if not removed from the body of the

deceased bef

ore cremation and some radioactive treatments may endanger the

health of crematorium staff.

If Yes, please give details and state whether it has been removed.

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4

Part 5 Inspection of certificates

You are entitled to inspect the certificates (if any) given by doctors under regulation 16(1)(c)(i) of the

Cremation (England and Wales) Regulations 2008 (forms Cremation 4 and Cremation 5). If you do

not wish to inspect any such certificates yourself you may nominate another person to inspect them

instead of you.

Such certificates will only be available for inspection at the offices of the cremation authority for

48 hours from the time that the cremation authority notifies you, or the person you have nominated,

that the certificates are available to be inspected. You may take someone with you when you attend

to inspect the certificates. If you, or the person nominated by you, do not attend to inspect the

certificates at the time agreed with the cremation authority, the cremation may then proceed.

Please state if you would like to inspect the certificates given by the doctors or whether you would like

to nominate someone else to do so instead and give a contact telephone number.

If certificates are given by medical practitioners:

I would like to inspect the certificates and

my contact telephone number is

I nominate

to inspect the certificates and their

contact

telephone number

is

Part 6 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.

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5

Cremation 1

6

Option 2: Ashes to be collected from the crematorium

Part 6 continued

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.

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 7 Recovery of ashes

Despite every effort being made to recover ashes following a cremation, on very rare occasions

(particularly with a cremation of stillborn children) 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 8 Statement of truth

I apply for the body of the person who has died 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

/ /

click to sign

signature

click to edit

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Fill Online, Printable, Fillable, Blank Form 1 Application For Cremation (Borough Council of King's Lynn and West Norfolk) Form

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