BIRTHS, DEATHS AND MARRIAGES
OFFICE OF REGULATORY SERVICES
Department of Justice and Community Safety

DEATH REGISTRATION STATEMENT		
Form 210 -DRS	

	Births Deaths and Marriages Registration Act 1997
Births Deaths and Marriages Registration Regulation 1998		

IMPORTANT INFORMATION
This form is used to collect particulars prescribed in the Births, Deaths and Marriages Registration Act 1997 and the Births Deaths and Marriages Registration Regulation 1998 to register the death of a person who died in the Australian Capital Territory. You can access legislation at www.legislation.act.gov.au. You may also obtain further information and forms from www.ors.act.gov.au 	
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 date 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 the 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.	
PRIVACY INFORMATION
The Births, Deaths and Marriages registration Act 1997 authorises the Registrar-General to collect the information required by this form.  The Registrar-General prevents any unreasonable intrusion into a person’s privacy in accordance with the Privacy Act 1988 (C’wlth). The Registrar-General may provide identifiable information to law enforcement organisations and authorised organisations that have legal authority to request information under prescribed circumstances. Documents provided as proof of identity may have their authenticity verified through Certificate Validation System (CVS) and the National Document Verification System (DVS). Documents issued by this office may also be verified by external agencies using CVS and/or DVS.	
CONTACT INFORMATION	
Send completed forms to the Office of Regulatory Services:	GPO Box 158, Canberra ACT 2601	
Lodge in person at the Office of Regulatory Services:	255 Canberra Avenue, Fyshwick ACT 2609	
Office Hours:	9:00am to 4:30pm Monday to Friday	
General enquiries telephone number:	(02) 6207 0460	
Website address:	www.ors.act.gov.au 	
Email address for enquiries	bdm@act.gov.au	
INSTRUCTIONS FOR COMPLETION
•	If completing this form by hand please use a blue or black pen only.
•	This office will not accept lodgement of this form if it is not completed in full.
•	Any alteration to information provided on this form must be struck through with a blue or black pen and substitute information must be clear and all parties must sign in the margin.  Do not use white out.
•	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. 
•	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.
•	A stepchild is not a child of the deceased.
•	There is no fee to lodge a death registration statement, however a fee is applicable if you require a death certificate. For information and forms to apply for a certificate please visit our website.	

If you require further information or need advice, a language assistance service is available by phoning the
Translating and Interpreting Service (TIS) on 13 14 50.

	BIRTHS, DEATHS AND MARRIAGES
OFFICE OF REGULATORY SERVICES
Department of Justice and Community Safety

DEATH REGISTRATION STATEMENT		
Form 210 -DRS	

	Births Deaths and Marriages Registration Act 1997
Births Deaths and Marriages Registration Regulation 1998		

DETAILS OF DECEASED	
Surname/Family Name
Given Names	Given Names
Place of Birth	
		
Surname/Family Name at Birth	Given Names at Birth	
		
Any other Surnames/Family Names Used	Any other Given Names Used	
		
Date of Birth	Date of Death	Sex 	Usual Occupation	
          /       /	           /        /			
Place of Birth (town/city and state/country)	Place of Death	
		
Last Home Address	
	
Was the deceased born outside Australia	If so, period of time in Australia	Was the death reported to the Coroner	
No     Yes		No       Yes	
Was the deceased of Aboriginal or Torres Strait Islander origin	
No     Yes, Aboriginal origin    Yes, Torres Strait Islander origin    Yes, both Aboriginal and Torres Strait Islander origin	

RELATIONSHIP DETAILS OF DECEASED AT TIME OF DEATH	
Was the deceased in a relationship at the time of death 	 No         Yes  (If yes, please indicate type below)	
  Domestic partnership              Civil Partnership             Married             Divorced              Widowed	
Name and former name of partner or spouse	Place of Marriage/Partnership (If Applicable)	Date	
		           /          /	

DETAILS OF ANY OTHER RELATIONSHIPS OF DECEASED	
Any domestic partnerships the deceased had been in at anytime including the date and place of marriage/partnership	
Name and former name of partner or spouse	Place of Marriage/Partnership (If Applicable)	Date	
		           /          /	
		           /          /          	
		           /          /	
		           /          /	

CHILDREN OF DECEASED (Please enter in order of birth)	
Given names in full	Date of Birth	Sex	Deceased	
	          /          /	 Female    Male	 No   Yes	
	          /          /	 Female    Male	 No   Yes	
	          /          /	 Female    Male	 No   Yes	
	          /          /	 Female    Male	 No   Yes	
	          /          /	 Female    Male	 No   Yes	
	          /          /	 Female    Male	 No   Yes	
	          /          /	 Female    Male	 No   Yes	
	          /          /	 Female    Male	 No   Yes	
	          /          /	 Female    Male	 No   Yes	

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

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

DETAILS OF DISPOSAL OF REMAINS (If applicable)	
Funeral director’s business/company name and phone number	Full name of funeral director or person responsible for disposal	
		
Address of funeral director or person responsible for disposal	If celebrant is a minister of religion specify the denomination	
…………………………………………………………………………………….…………………		
	Full name of celebrant if present at burial or cremation	
		
Date of disposal	Manner of disposal of remains	
       /        /	 Burial	 Cremation	 In custody of educational/scientific institution	 Removal from ACT	
Place of disposal of remains	Full name 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	Address of funeral director or person responsible for removal	
		
Given name of funeral director or person responsible for removal	Occupation of person responsible for removal 	
		
Date of removal	Purpose of removal and if for anatomical examination name of the institution where this 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 the person having custody of the remains	
		
Address of person having custody of the remains	Occupation of the person having custody of the remains	

CERTIFICATION OF PERSON PROVIDING INFORMAITON 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 a person who intentionally makes a false statement in a statutory declaration is guilty of an offence under section 11 of the Statutory Declarations Act 1959, and I believe that the statements in the declaration are true in every particular. 

Full name	Occupation 	
		
Address 	Signature	
		
Daytime telephone number	Relationship to deceased