Stillborn Cremation Application

Application for permission for cremation of still-born child with statutory declaration.
Public Health Regulation, 2022 Section 105

(This form should be completed by the nearest surviving relative of the deceased or if no nearest surviving relative is available, other proper person, and all questions must be fully answered)
I, (Full Name of Applicant)
Applicants Address
Postcode
Age
hereby apply for permission to cremate the remains of
Name of Still Born Child
at the Crematorium
Location of Crematorium
1. (a) Are you the nearest surviving relative of the child? If so, state relationship
(b) If not nearest surviving relative, state EITHER
(i) relationship to still-born child
(ii) reason(s) why this application is being made by you
OR:
Complete the following statement:
I have been requested by
(Name and relationship to deceased)
to make this application of cremation and I am fully aware of the information contained herein.
(c) (i) Have all near relatives of the deceased been informed of the proposed cremation?
(ii) Has any near relative of the deceased expressed any objection to the cremation?
If so, state the reasons for objection
2. When did the still-birth occur?
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Time

Hour Minutes

AM/PM Option
3. Where did the still-birth occur? (State address and location, i.e. own residence, hospital, hotel, etc)
4. Give the name and address of the medical practitioner who attended the still-birth
5. Give the name of the Registry Office where the death has been, or is to be, registered
I hereby certify that all particulars stated above are true and accurate, and that to the best of my knowledge and belief no particular material has been omitted; I therefore make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths Act, 1900.

I am aware that the deceased may not be cremated on the day of the service at the crematorium.
Declared at
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Signature
Instructions for ID Verification.
1. Take a Picture of the Document that the JP will use to verify your identity.
2. The Picture must be clear.
3. It must show your full name
4. It must show your address
5. It must show the type of Document that the Document is.
6. The JP Will Do a Video Call and verify your identity using the information and picture provided.
7. Once your identity is verified, the picture of the document will be destroyed.
Take Photo
Following details are for the JP use only.
I,
a ,
certify the following matters concerning the making of this statutory declaration by the person who made it:
person had a special justification for not removing the covering.
AND
identification document and the document I relied on was
(Describe identification document relied on)

Signature of authorised witness:
Date
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Application for permission for cremation of still-born child with statutory declaration.

Following details are for the JP use only.