SCHEDULE.
FORM A.
Application for Cremation
1. (Name of Applicant)
(Address)
(Occupation)
apply to the
to undertake the cremation of the remains of
(Name of Deceased)
(Address)
(Occupation)
Age) (Sex)
(Whether married, widow, widower, or unmarried)
The true answers to the questions set out below are as follows:-
1. Are you an executor or the nearest surviving relative of the deceased?
2. If not, state
(a) Your relationship to the deceased.
(b) The reason why the application is made by you and not by an executor or any nearer relative.
3. Did the deceased leave any written directions as to the mode of disposal of his/her remains? If so, what?
4. Have the near relatives* of the deceased been informed of the proposed cremation?
* The term "near relative" as here used includes widow or widower, parents, children above the age of 16, and any other relative usually residing with the deceased.
5. Has any near relative of the deceased expressed any objection to the proposed cremation? If so, on what ground?
6. What was the date and hour of the death of the deceased?
7. What was the place where deceased died? (Give address and say whether own residence, lodgings, hotel, hospital, nursing home, etc.)
8. Do you know, or have you any reason to suspect, that the death of the deceased was due, directly or indirectly, to
(a) violence;
(b) poison;
(c) privation or neglect?
9. Do you know any reason whatever for supposing that an examination of the remains of the deceased may be desirable?
10. Give name and address of the ordinary medical attendant of the deceased.
11. Give names and addresses of the medical practitioners who attended deceased during his/her last illness.
I declare to the best of my knowledge and belief that the information given in this application is correct and no material particular has been omitted.
Date ....................... (Signature) ....................
The applicant is known to me and I have no reason to doubt the truth of any of the information furnished by the applicant.
Date ....................... (Signature) ....................
(Capacity in which signatory has
signed)........................
(Address) ......................
......................
......................
(a) 2 Edw. 7. c. 8.
(b) 15 & 16 Geo. 6. & 1 Eliz. 2. c. 31.
(c) 16 & 17 Geo. 5. c. 48.
(d) S.R. & 0. 1930/1016; Rev. V, p. 283; 1930 p. 417.