CEMETERIES AND CREMATORIA REGULATIONS 2003
SECTION 9	
Application for Burial or Cremation of Foetal Remains
	
The particulars given herein will be regarded as strictly confidential	

Stillborn of……………………………………………………………(Mother’s or Mother’s and Father’s name)

Date of death (if unknown approximate date)……….……………………………………………...……………..

Gestation (if known)…………………………………Weight of foetal remains……………………….…(grams)

At least one parent’s details needs to be filled in below

Particulars of mother

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

Permanent address (as per hospital identification)………...……………………..…………….………………….

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

Particulars of father

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

Permanent address…………………………………………..…………………….……………………………….

Section to be filled out by the doctor or nurse attending             Are remains infectious?  No     Yes  

I certify that the remains are foetal and there is no known reason why they should not be buried/cremated

Signature………………………………………………………..….Date………………….………………………

Name (in block letters)……………………….…………………….Qualifications…….……………...………….

Address……………………………..……………………………………….Telephone…………………………..

I would like to …………………..(cremate or bury) the remains of the deceased individually, and will make the arrangement myself.

Signature………………………………………………………….Date…………………………………………...

Name (in block letters)………………………………………………………….Mother/Father………………….

Witness of Signature……………………………………………...Date…………………………………………..

Name of Witness (in block letters)………………………………………………………………………………...

I understand that the foetal remains will be cremated as a group and there will be no individual marking of ashes and that these ashes will be disposed of appropriately by the hospital.

Parent’s Signature………………………………………………………….Date………………….……………...

Name (in block letters)………………………………………………………….Mother/Father………………….

Witness of Signature…………………………………………..…………...Date………………..………………..

Name of Witness (in block letters)………………………………………………………………………………...