Victorian Numbered Regulations Victorian Numbered RegulationsSch. 3
Cemeteries and Crematoria Act 2003
Cemeteries and Crematoria Regulations 2005
APPLICATION FOR CREMATION AUTHORISATION
Name of crematorium at which cremation is to take place:
Details of deceased
Full name:
Sex: *Male *Female
Date of birth:
Date of death:
Age:
Last known permanent address:
Religion if any:
Did the deceased have a spouse or domestic partner at the time of his or her death? *Yes *No
Did the deceased leave any written directions as to the mode of disposal of his or her remains? *Yes *No
If Yes, give particulars and attach any relevant documentation.
Did the deceased, during his or her last illness, orally in the presence of 2 witnesses expressly or implicitly request that his or her bodily remains not be cremated? *Yes *No
If Yes, give particulars.
Applicant for Cremation Authorisation
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Full name:
Address:
Telephone number:
Email:
Relationship to the deceased:
Cremated Remains
I, the applicant, state that I have the full authority to determine to whom the cremated remains of the deceased are to be provided and the way in which these cremated remains are to be dealt with.
Following cremation, the cremated remains are to be:
* Memorialised at:
* Collected by:
* Held at crematorium for up to 12 months after the cremation:
* Other (please specify):
Please note that cemetery trusts are required to hold the cremated remains for at least 12 months after the cremation. Following the expiry of the 12-month period, the cemetery may dispose of the cremated remains in any way that it considers appropriate.
* If you would like to nominate an agent to collect the cremated remains provide the following details:
Full name of agent:
Address:
Telephone number:
Other matters
Provide details of the deceased's usual registered medical practitioner:
Full name:
Address:
Telephone number:
Provide details of any other registered medical practitioners attending the deceased during the deceased's last illness:
Full name:
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Address:
Telephone number:
If the deceased died in a hospital or other health or aged care service, provide the name of the service:
If the deceased died in a place other than a hospital or other health or aged care service, provide:
A. The name and relationship to the deceased of any person who nursed the deceased during his or her last illness:
Full name:
Relationship to the deceased:
Address:
Telephone number:
Fax:
Email:
Full name:
Relationship to the deceased:
Address:
Telephone number:
Fax:
Email:
and
B. The name of any person present at the moment of the deceased's death:
Full name:
Relationship to the deceased:
Address:
Telephone number:
Fax:
Email:
Full Name:
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Relationship to the deceased:
Address:
Telephone number:
Fax:
Email:
Signature of applicant: Date:
Statement by funeral director
This section should be filled out by the funeral director or the person who otherwise arranged for the disposal of the human remains.
* Removal of pacemaker or other battery-powered device from the deceased is not required.
* I have arranged for any pacemaker or other battery-powered device referred to on the medical certificate of cause of death to be removed from the deceased as required by the relevant cemetery trust.
Signature: Date:
*Company name:
Full name of contact person:
Address:
Telephone:
Email:
* Delete if not applicable
WARNING
Under section 132 of the Cemeteries and Crematoria Act 2003 it is an offence to make a false statement in an application for a cremation authorisation, punishable by a fine of up to 600 penalty units or 5 years imprisonment or both.
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