Attended Cremation Application Form

Application for Attended Cremation

Application for Permit to Cremate, Instructions for Ashes, Sixth Schedule and Death Registration.
Name of Deceased*

First NameMiddle Name (if applicable)Last Name
Name of Deceased Full
Gender

MaleFemaleN/A
Gender Full
Date of Birth*

DayMonthYear
Date of Birth
Age
Age
Place of Birth

Suburb

Street Address Line 2

Suburb/TownState

Postal / Zip CodeCountry
Usual Residence / Address

Building/Hospital Name

Street Address

CityState

Post Code
Year Arrived in Australia
Year
Years in Australia
Address of Deceased Full
Usual Occupation During Working Life
Occupation
Marital Status

MarriedDivorcedWidowedNever MarriedUnknown
Marital Status Full
Spouse name

First NameLast Name
Marriage Details

Date of MarriagePlace of Marriage
Any Children of the Deceased

YesNo
First Child

Given NamesGender
First Child DOB

DayMonthYear
Date of Birth
First Child Age
Second Child

Given NamesGender
Second Child DOB

DayMonthYear
Date of Birth
Second Child Age
Third Child

Given NamesGender
Third Child DOB

DayMonthYear
Date of Birth
Third Child Age
Fourth Child

Given NamesGender
Fourth Child DOB

DayMonthYear
Date of Birth
Fourth Child Age
Fifth Child

Given NamesGender
Fifth Child DOB

DayMonthYear
Date of Birth
Fifth Child Age
Sixth Child

Given NamesGender
Sixth Child DOB

DayMonthYear
Date of Birth
Sixth Child Age
Mother of the Deceased

First NameLast Name
Occupation
Maiden Surname (if applicable)
Father of the Deceased

First NameLast Name
Occupation
Usual Doctor / GP

NameAddress
Please provide the details of the last doctor to see the deceased

NameAddress
misc

no instructions for ashesno objections to cremationsrelationship to deceasedexamination not requiredprevious permit
cemetery
Date of Death

DayMonthYear
Date of Death
Place of Death

HomeHospitalOther
Place of Death

Building/Hospital Name

Street Address

CityState

Post Code
Date

DayMonthYear
Date
Date separated

MonthDayYear
Has the Coroner conducted an investigation into the death of the deceased?

YesNo
In Which Cemetery Will The Cremation Service Take Place?
In Which Cemetery Will The Cremation Service Take Place?

Pinnaroo CemeteryKarrakatta CemeteryFremantle Cemetery
Details of Applicant*

First NameLast Name
Name of Applicant Full
Mobile NumberE-mail
Relationship to the Deceased
Address of Applicant

Street Address

Street Address Line 2

CityState

Post CodeCountry
Address of Applicant Full
I certify that the information provided is, to the best of my knowledge and belief, true and correct for the purpose of being inserted in the Register of Deaths.
Signature*

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Application for Attended Cremation