CEMETERIES AND CREMATORIA REGULATIONS 2003
SECTION 7	
Application for Burial	NOTE:       1. Application must be lodged with a Cemetery before burial can take place.
2. Application is to be completed by the executor or nearest surviving relative of the deceased
3. All questions must be answered fully.
WARNING:  Maximum penalty for furnishing a document which is false or misleading in a material 

The particulars given herein will be regarded as strictly confidential	
I hereby apply for the burial of the remains of the deceased described hereunder (Please use block letters)

Surname of deceased…………………………………………….Other names.……………………………………………..

Address………………………………………………………………… Occupation…………………………………….....

Date of Birth (if known)…………………………..  Age (if date unknown give age as accurately as possible)……………

Sex…………… Marital status (eg. married, unmarried, widow, widower or defacto).……………………………………..

Name of cemetery to whom application is made………………………………………………………………….. 

Particulars of applicant (the applicant is the person who is to become the holder of the Right of Burial)

Surname………………………………………………………….Other names………………………………………………

Permanent Address……………………………………………………………….…….….Occupation……………….……..

To the best of my knowledge the answers given to the questions set out below are true:

1. Are you an executor or nearest surviving relative of the deceased?………. If the answer is ‘No’ please complete (a) and (b) below:
(a)	Relationship to the deceased:…………………………………………………………………………………………….
(b)	State why the application is made by you and not by an executor or nearest surviving relative.

………………………………………………………………………………………………………………………………...

2. Did the deceased leave any written directions as to the mode of disposal of his/her remains?……………………..……..

If the answer is ‘Yes’ say what directions…………………………………………………………………………..………..

3. Have the nearest relatives of the deceased been informed of the proposed burial?………(NOTE: The term near relative here used includes widow, widower, parents, domestic partners, children above 16 years and any other relative residing with the deceased).

4. Has any near relative of the deceased expressed any objection to the proposed burial?…….If the answer is ‘Yes’ say 

on what grounds:……………………………………………………………...…………………………...………………….

5. Date of Death……../……../……..  Hour of Death……….am/pm.  

6. Address where deceased died…………………………………………………………….………………………..…….…

Say whether own residence, lodgings, hotel, hospital, nursing home etc…………………………………………………….

Death Certificate

Has a death certificate been supplied?…….Doctor issuing certificate………………………….Date issued……………….

SIGNATURE OF APPLICANT…………………………………………………….………. Date……………………….…

WITNESS OF SIGNATURE…………………………………………………….………….. Date………………………….

NAME OF WITNESS……………………………………………………………………..…………………………………