CITY OF BELFAST CREMATORIUM

CITY OF BELFAST CREMATORIUM
Cremation No.
For offical use only
APPLICATION FOR CREMATION
PURSUANT TO REGULATIONS MADE BY THE MINISTRY OF HEALTH AND LOCAL GOVERNMENT UNDER SECTION 7 OF THE CREMATION ACT, 1902, AS APPLIED BY SECTION 26 OF THE BELFAST CORPORATION (GENERAL POWERS) ACT (NORTHERN IRELAND), 1948
This application should be made by executor or nearest relative whenever practicable
Name

1. (Name of APPLICANT - Surname first, other names in full)(ADDRESS)
(OCCUPATION)
Apply to the Belfast City Council to undertake the cremation of the remains of
(NAME OF DECEASED)
Surname first. Other names in full
(ADDRESS)
(ADDRESS OF DECEASED)
(OCCUPATION OF DECEASED)
(AGE)
(SEX)
(WHETHER MARRIED OR IN A CIVIL PARTNERSHIP, SURVIVING SPOUSE OR CIVIL PARTINER OR SINGLE (NEVER MARRIED OR NEVER HAVING FORMED A CIVIL PARTNERSHIP)
The true answers to the questions set out below are as follows:
1. Are you an executor or the nearest relative of the deceased? (State which and if the nearest relative, show relationship)
(Move to box 3 if you have answered 'YES' for box one) 2. If you are not an Executor or nearest relative, state (A) Your relationship to the deceased
2. If you are not an Executor or nearest relative, state (b) The reason why the application is made by you and not by an executor or nearer relative (For example - due to sickness)
3. (A) Did the deceased leave any written directions as to the mode of disposal of his or her remains?
3. (B) If so, What?
4. Have the near relatives of the deceased been informed of the proposed cremation? (Yes OR No)
5. Has any near relative of the deceased expressed any objection to be 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 the deceased died? (Give address and say whether own residence, lodging, hotel, hospital, nursing home, etc)
8. Do you know or have any reason to suspect that the death of the deceased was due, directly or indirectly, to (A) violence or misadventure
8. Do you know or have any reason to suspect that the death of the deceased was due, directly or indirectly, to (B) unfair means
8. Do you know or have any reason to suspect that the death of the deceased was due, directly or indirectly, to (C) negligence or misconduct
8. Do you know or have any reason to suspect that the death of the deceased was due, directly or indirectly, to (D) malpractice on the part of others
8. Do you know or have any reason to suspect that the death of the deceased was due, directly or indirectly, to (E) any cause other than natural illness or disease for which he or she had been seen and treated bt a registered medical practitioner within 28 days prior to death?
9. Do you know or have any reason to suspect that the death of the deceased occured while he or she was under anaesthetic?
10. Do you know any reason whatsoever for supposing that an examination of the remains of the deceased may be desirable?
11. Give name and address of the ordinary medical attendant of the deceased.
12. Give names and addresses of the medical prectisioners who attended deceased during his or hers last illness.
THIS DECLARATION MUST BE MADE BEFORE A JUSTICE or THE PEACE
I do herehy solemnly and sincerely declare that all the particulary stated above are true, and that to the best of my knowledge and belief no material particular has been omitted: and I make this solemn declaration conscientiously believing the same to be true and by virtse of the Statutory Declaration Act, 1835.
Signature

Clear
Declared at
the day
of the month and year
Before me.

(Signature) George Teggart

(Description) Justice of the Peace

THIS FORM. WHEN COMPLETED, MUST BE DESPATCHED TOGETHER WITH THE DISPOSAL CERTIFICATE TO THE MEDICAL REFEREE, C/O CITY AND NEIGHBOURHOOD SERVICES, BEREAVEMENT SERVICES, THE CECIL WARD BUILDING 4-10 LINENHALL STREET. BELFAST, BT2 8BP. FORMS B AND C (OR IN THE CASE OF AN INQUEST THE CORONER'S CERTIFICATE F) SHOULD, WHERE POSSIBLE BE SENT AT THE SAME TIME.
Should be Empty:

CITY OF BELFAST CREMATORIUM

APPLICATION FOR CREMATION

PURSUANT TO REGULATIONS MADE BY THE MINISTRY OF HEALTH AND LOCAL GOVERNMENT UNDER SECTION 7 OF THE CREMATION ACT, 1902, AS APPLIED BY SECTION 26 OF THE BELFAST CORPORATION (GENERAL POWERS) ACT (NORTHERN IRELAND), 1948

(ADDRESS)