Western Australian Consolidated Regulations Western Australian Consolidated Regulations[Forms A and B deleted]
Form B(1)
To the Principal of
the……………………………………
School of Anatomy.
It is my wish that my remains after death be anatomically examined at the
………………………………………………….School
of Anatomy for the advancement of medical education.
My personal particulars are: —
Full Name:
………………………………………………………………………..............
Usual Address:
…………………………………………………………………...............
Date of Birth:
…………………………………………………………………….............
Religious Persuasion:
……………………………………………………………............
Name and address of senior next of kin:
……………………………………………………………………………………..
Preference as to disposal of remains (burial or cremation):
……………………...............
……………………………………………………………………………………
I have/have not made a will. (Give name and address of executor if will made.)
Signature:
……………………………………………………...
Witness (signature):
…………………………………….……….
(Address):
………………………………………………………..
Note. — Persons who offer their remains for anatomical
examination should inform their senior next of kin of their wishes and ask
them to co‑operate with the School of Anatomy. If a will has been made
it is important that the executor be informed also. A copy of this statement
will be supplied for filing with the will on request.
[Form B(1) amended in Gazette 30 June 2003 p. 2592.]
Form B(2)
To the Principal of the
…………………………………………………………................
School of Anatomy.
In accordance with the wish expressed by the late
……………………………….............
………………………………………of…………………………………………..............
who died at
………………………….….on
……………………………………..............
I have arranged for his/her body to be delivered to you by
……………………...............
…………………………………………………for
anatomical examination.
Particulars of the deceased person are as follows: —
Full
Name:………………………………………………………………………...............
Usual
Address:……………………………………………………………………............
Date of
Birth:……………………………………………………………………...............
Religious
Persuasion:……………………………………………………………...............
Preference as to disposal (burial or
cremation):…………………………………..............
……………………………………………………………………………………..
Name and Address of executor or administrator of estate, if this advice is not
completed by the executor or administrator
………………………….................................
……………………………………………………………………………………..
……………………………………………………………………………………..
Name and address of senior next of
kin:…………….........................................................
……………………………………………………………………………………..
……………………………………………………………………………………..
(Signature of
Informant):…………………………………....
Status of Informant (Executor, Administrator,
senior next of kin,
etc.):…………………………….........
..........................................................................................
Date:………………………………………….......................
Note. — This form, together with a copy of the Death
Certificate, should be delivered to the School of Anatomy with the body.
If the senior next of kin is available they should be requested to complete
and sign the following statement: —
I,……………………………….……of
…………………………………..............
being the senior next of kin, agree to the anatomical examination of his/her
body in accordance with his/her wishes.
(Signature):…………………………………..
(Relationship):……………………………….
(Address):……………………………………
…………………………………………….....
[Form B(2) amended in Gazette 30 June 2003 p. 2592.]
Form C
Notice to the Executive Director, Public Health and Scientific Support
Services of the intended Removal of a Body for the Purpose of Anatomical
Dissection.
Date……………………….............19……….
Sir,
I desire to inform you that it is my intention to remove to
the…………………................
School of Anatomy the body
of…………………, an inmate
of………………................,
who died here
on………………………………,
at the hour of…………………..............
Religious Persuasion of
Deceased……………………......Sex………........Age………....
During life * he/she has never expressed to me, nor, so far as I know, to any
other person, a wish that * his/her remains should not be submitted to
anatomical examination.
I certify that the death in this case was not caused by an infectious disease,
and that a medical certificate of the cause of death has been given.
(Official
Designation)………………………….(Signed)………………………...............
* Delete word not applicable.
Form D
Notice to the Principal of
the……………………………….School
of Anatomy.
Date………………………………..19…….
Sir,
I herewith send you, per
(a)…………………………the
body of………………...............
a
(b)…………………………..who
died on
(c)………………………………................at
(d)…………………………………..aged
(e)………........(f)…………………………......
A certificate signed by a duly qualified medical practitioner and stating the
cause of death must be furnished with this form.
(Signed)………………….......……….
Lawful Custodian of Body.
(a) Here state name of conveyor of body. (b) Here state sex. (c) Date of
death. (d) Place of death. (e) Age. (f) Religion of Deceased.
Form E
Register No.
………………………………..
………………………………………School
of Anatomy.
Date…………………………19……….
Received this day,
from…………………………the
body of…………………….............
lately an inmate
of……………………………
…………………………………………
Principal
Form F
Register No.
………………………………..
Notice from the Principal of
the………………………………………..School
of Anatomy to the Executive Director, Public Health and Scientific Support
Services of Receipt of Body for Anatomical Examination.
Date…………………………19……….
Name of
Deceased………………………………………………………………...............
Sex……….Age (as far as
known)………………..Late
abode…………………...............
Date of
Death……………………………..Place
of
Death……………………….............
Religious
Persuasion……………………………
Day and hour of receiving body at School of Anatomy —
By whom
brought………………………………
To whom
delivered………………………………
_________________
I certify that I received with the body the certificate of the cause of death
of………..…………………………………………which
I herewith enclose.
(Signed)………………………………….
Form G
Register No.
………………………………..
Notice from the Principal of
the………………………………………..School
of Anatomy to the Executive Director, Public Health and Scientific Support
Services of having returned, for the purpose of sepulture, the remains of
persons which have undergone Anatomical Examination.
|
Name of Person whose dissected remains are to be buried. |
When Received. |
To whom given for Burial; that is to say, for Conveyance to the Cemetery. |
Religious Persuasion of Deceased. |
|
|
(Signed)………………………………………..
(Date)……………………………….19……….
Form H
Register No.
………………………………..
Authority for burial of remains of Person who has undergone
Anatomical Dissection.
Date……………………………19……….
To…………………………………………
..........................................................................
Sir,
You are requested to arrange the interment of the remains of
………………........ in the
………………………………
portion of the
………………………......
Cemetery.
Details of deceased are as follows: —
Date of
death……………………………..
Age……………………………………….
Sex………………………………………..
Religious Persuasion……………………..
……………………………………………….
Principal.
……………………………………………….
School of Anatomy.
Form I
Register No.
………………………………..
Acknowledgment of having received Dissected Remains of Body for
Interment.
I, this day received for interment, from
the…………………….....…….School
of Anatomy the remains
of…………………………………………….........whose
body was delivered at the School of Anatomy on
the…………………………..........….and
was entered in “Receiving Book” under the
No.
……………………………….
(Signed)…………………………………..
(Date)………………………….19……….
To be filed and kept by the Principal of the School of Anatomy.
Form J
Register No.
………………………………..
Notice to the Executive Director, Public Health and Scientific Support
Services by Person receiving Dissected Body
from……...............…………………………..School
of Anatomy for the purpose of Burial.
Date……………………………19……….
Sir,
I, this day, received the remains
of…………….……..........……..and
conveyed same to ( *
)……………………..........for
sepulture in the
(†)………………………........portion
of the Cemetery.
Accompanying is the certificate of the officiating clergyman.
(Signed)…………………………………
(Address)…………………………………
( * ) Here name Cemetery (†) Here state Denomination
[Schedule A inserted in Gazette
2 July 1948 pp.1467‑9; amended in Gazettes
17 December 1948 p.2975, 12 June 1958 pp.1291‑2;
29 June 1984 p.1781; 22 January 1999 p.213;
30 June 2003 p.2592.]