DRS
Form 210

ACT GOVERNMENT
Births, Deaths and Marriages Registration Act 1997
Registrar-General’s Office
DEATH REGISTRATION STATEMENT

PRIVACY COLLECTION STATEMENT (PRIVACY ACT 1988 (C’WLTH))

PRIVACY NOTES

The Births, Deaths and Marriages Registration Act 1997 authorises the Registrar-General to collect the information required by this form for the establishment and maintenance of registers and in processing your application.  The Registrar-General prevents any unreasonable intrusion into a person’s privacy in accordance with the Privacy Act 1988 (C’wlth).  However, the Registrar-General provides identifiable information to law enforcement organisations and authorised organisations that have legal authority to request information under prescribed circumstances.	

WHO IS RESPONSIBLE FOR NOTIFICATION

The funeral director or person who arranges for the disposal of human remains in the ACT must, within 7 days after the day the remains are disposed of, give the Registrar-General a written statement containing certain information.  Disposal of remains includes cremation, burial, placing the remains in the custody of an educational or scientific institution for the purpose of medical education or research or, removal from the ACT.  If the remains are removed from the ACT, the funeral director or person who arranges the removal should also provide a written statement within 28 days of disposal outside the ACT to the Registrar-General containing certain information.  If the remains have not been disposed of within 30 days of the date of death, the funeral director or the person having custody of the remains must provide a written statement to the Registrar-General containing certain information.  This form is to be used to provide this information to the Registrar-General.	

CORONIAL INQUESTS

Where a death is subject to a coronial inquest a death certificate may not be issued with a cause of death until the Coroner’s Office has notified this office of the cause of death.  The Registrar-General may issue a death certificate after registration without a cause of death until such time as the Registrar-General has been provided with the Coroner’s findings.	

GENERAL INFORMATION

A domestic partnership is defined in the Legislation Act 2001 as a relationship between 2 people, whether of a different or the same sex, living together as a couple on a genuine domestic basis.  A domestic partner may include a husband or wife through a marriage.  Also note a stepchild is not a child of the deceased.  A Parent is defined in the Legislation Act 2001 as a mother, father or someone else who is presumed to be a parent under the Parentage Act 2004. The statistical information relating to Aboriginal or Torres Strait Islander origin are collected for the Australian Bureau of Statistics for health and welfare purposes only.	

FEES CURRENT TO 30 JUNE 2008

There is no fee to lodge a death registration statement, however a fee is applicable if you require a death certificate.  If you wish to apply for a death certificate you may obtain an application form from our website or contact this office.	

CONTACT DETAILS

The Registrar-General’s Office is located at 255 Canberra Avenue, Fyshwick ACT 2609.  Our postal address is PO Box 225, Civic Square ACT 2608.  Our office hours are 9:00am to 4:30pm Monday to Friday.  You may also download forms and information from our website at www.rgo.act.gov.au or contact this office on (02) 6207 0460.	

Telephone Interpreter Services	
If English is not your first language, and you need help with this form, please telephone 131 450 for assistance 24 hours a day.

DRS
Form 210

Registration No

Certificate Applied For (Office use Only) Y / N

ACT GOVERNMENT
Births, Deaths and Marriages Registration Act 1997
Registrar-General’s Office
DEATH REGISTRATION STATEMENT
DETAILS OF DECEASED	
Surname		Given names	
			
Surname at birth		Given names at birth	
			
Any other surnames used		Any other given names used	
			
Last home address 	
	
Date of death		Place of death	
        /          /			
Date of birth		Place of birth (town/city and state/country)	
        /          /			
Sex		Was the deceased born outside Australia		If so, the period of time in Australia	
		                         Yes / No			
Usual occupation		Was the death reported to the Coroner	
		                                              Yes / No	
Was the deceased of Aboriginal or Torres Strait Islander origin (for Australian Bureau of Statistics purposes only)	
 No         Yes, Aboriginal origin         Yes, Torres Strait Islander origin         Yes, both Aboriginal and Torres Strait Islander origin	

MARITAL AND DOMESTIC PARTNERSHIP DETAILS OF DECEASED	
Was the deceased in a domestic partnership at time of death		Marital status immediately prior to death	
                                         Yes / No		Never married        Married        Widowed        Divorced 	
Domestic partnerships the deceased had been in at any time including date and place of each marriage if applicable	
Name and any former name of each domestic partner or spouse	Date of marriage	Place of marriage	
	        /          /		
	        /          /		
	        /          /		

CHILDREN OF DECEASED	
Enter in order of birth. If child is deceased write ‘D’ in the age.  Include adopted children but not those given up for adoption or stepchildren.	
Given names in full	Sex	Age		Given names in full	Sex	Age	

							

DETAILS OF DECEASED’S MOTHER	
Surname		Given names	
			
Maiden / Former names if any		Occupation	

DETAILS OF DECEASED’S FATHER  PARENT  	
Surname		Given names	
			
Maiden / Former names if any		Occupation	

DETAILS OF DISPOSAL OF REMAINS (IF APPLICABLE)	
Surname of funeral director or person responsible for disposal		Given names of funeral director or person responsible for disposal	
			
Address of funeral director or person responsible for disposal		Funeral director’s business/company name and telephone number 	
			
Date of disposal 		Manner of disposal of remains ie burial, cremation, in custody of educational/scientific institution or removal from ACT 	
        /          /			
Place of disposal of remains	
	
Full name of celebrant if one was present at burial or cremation		If celebrant is a minister of religion specify the denomination	
			
Surname of person who witnessed disposal of remains		Given names of person who witnessed disposal of remains	

STATEMENT OF REMOVAL OF REMAINS FROM THE ACT (IF APPLICABLE)	
Surname of funeral director or person responsible for removal		Given names of funeral director or person responsible for removal	
			
Address of funeral director or person responsible for removal		Occupation of funeral director or person responsible for removal	
			
Date of removal		Purpose of removal and if it was for anatomical examination the name of the institution where it is to take place 	
        /          /			

STATEMENT OF NONDISPOSAL OF REMAINS WITHIN 30 DAYS OF DEATH (IF APPLICABLE)	
Surname of person having custody of the remains		Given names of person having custody of the remains	
			
Address of person having custody of the remains		Occupation of person having custody of the remains	

CERTIFICATION OF PERSON PROVIDING INFORMATION TO FUNERAL DIRECTOR	
I certify that I have read this form thoroughly and that the information provided, is to the best of my knowledge and belief, true and correct for registration purposes.  I understand that it is an offence to make a false or misleading statement in any application or document under the Births, Deaths and Marriages Registration Act 1997.	
Full name		Address	
			
Occupation		Daytime telephone number		Relationship to deceased		Signature