Form 1 "Application for a Permission to Cremate" - Queensland, Australia

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Form 1
Queensland
Cremations Act 2003
(Section 6(1))
APPLICATION FOR A PERMISSION TO CREMATE
Please print all information on this form.
To:
!
Coroner
!
Independent Doctor
(The application has to be to a coroner if an autopsy was or is being conducted under the Coroners Act 1958 or the Coroners Act
2003. Otherwise the application is to be made to an independent doctor – section 5 of the Cremations Act 2003.)
I,
,
(print name in full)
whose address for service to be included on the Permission to Cremate is:
(print address for service in full)
Telephone No:
apply for a permission to cremate the human remains of:
Name of deceased person:
Usual or last known address of deceased person
:
(if known)
Date and place of death of deceased person
:
(if known)
Age of deceased person:
:
Date of birth of deceased person
:
(if known)
(if known)
1.
(Complete either A or B - use B only if an agent)
A.
(Tick one box only)
I am a:
!
spouse
!
child who is at least 18 years
!
parent
!
brother who is at least 18 years
!
sister who is at least 18 years
!
appropriate person according to the tradition or custom of the community to which the deceased person
belonged
(only applies if the deceased was an Aboriginal or Torres Strait Islander)
!
personal representative
(under section 36 of the Acts Interpretation Act 1954 a personal representative is the
deceased person’s executor or administrator)
of the deceased person.
!
another adult person who is making the application because:
(print here reason why none of the persons referred to above have made the application, eg, none of the persons
referred to above are available.)
B.
I am an agent of a person referred to in A namely:
(print particular person referred to in A, eg, spouse/sister who is at least 18 years)
Form 1 ver. 1 – 31/10/03
Form 1
Queensland
Cremations Act 2003
(Section 6(1))
APPLICATION FOR A PERMISSION TO CREMATE
Please print all information on this form.
To:
!
Coroner
!
Independent Doctor
(The application has to be to a coroner if an autopsy was or is being conducted under the Coroners Act 1958 or the Coroners Act
2003. Otherwise the application is to be made to an independent doctor – section 5 of the Cremations Act 2003.)
I,
,
(print name in full)
whose address for service to be included on the Permission to Cremate is:
(print address for service in full)
Telephone No:
apply for a permission to cremate the human remains of:
Name of deceased person:
Usual or last known address of deceased person
:
(if known)
Date and place of death of deceased person
:
(if known)
Age of deceased person:
:
Date of birth of deceased person
:
(if known)
(if known)
1.
(Complete either A or B - use B only if an agent)
A.
(Tick one box only)
I am a:
!
spouse
!
child who is at least 18 years
!
parent
!
brother who is at least 18 years
!
sister who is at least 18 years
!
appropriate person according to the tradition or custom of the community to which the deceased person
belonged
(only applies if the deceased was an Aboriginal or Torres Strait Islander)
!
personal representative
(under section 36 of the Acts Interpretation Act 1954 a personal representative is the
deceased person’s executor or administrator)
of the deceased person.
!
another adult person who is making the application because:
(print here reason why none of the persons referred to above have made the application, eg, none of the persons
referred to above are available.)
B.
I am an agent of a person referred to in A namely:
(print particular person referred to in A, eg, spouse/sister who is at least 18 years)
Form 1 ver. 1 – 31/10/03
2
2.
(Tick one box only)
!
The deceased person left/did not leave
signed instructions that his/her
(delete whichever does not apply)
(delete
human remains be cremated.
whichever does not apply)
!
I do not know whether the deceased person left instructions that his/her
human
(delete whichever does not apply)
remains be cremated.
Note: If the deceased person left signed written instructions that his/her human remains be cremated then:
!
if the personal representative is arranging the disposal of the human remains he/she must ensure an application for
a permission to cremate is made (section 7(2) of the Cremations Act 2003); and
there is no obligation to have regard to any objections to the cremation (section 8(1) of the Cremations Act 2003).
!
3.
(Tick one box only)
!
To the best of my knowledge I am not aware that any of the following people have any objection to the cremation
of the human remains of the deceased person: spouse, adult child, parent or personal representative.
!
The deceased person’s spouse, adult child, parent or personal representative
has
(delete whichever does not apply)
objected to the cremation of the human remains of the deceased person.
Note:
The Permission to Cremate cannot be issued if there is an objection from one of the persons referred to (section 8(2) of the
Cremations Act 2003) unless the deceased person left signed written instructions that his/ her human remains be cremated
(section 8(1) of the Cremations Act 2003).
4.
(Tick one box only)
!
The deceased person’s human remains contain a cremation risk
(please specify, eg, cardiac pacemaker):
!
The deceased person’s human remains do not contain a cremation risk.
!
I do not know whether the deceased person’s human remains contain a cremation risk.
Note: Human remains pose a cremation risk if the remains contain something that, if cremated, might expose someone to the
risk of death, injury or illness (for example, a cardiac pacemaker or radioactive implant: section 6(7) of the Cremations Act
2003).
5.
(Complete only where the application is to an independent doctor. Tick one box only.)
The following documents accompany this application to an independent doctor:
!
copy of cause of death certificate issued for the deceased person; and a cremation risk certificate for the
deceased person
(Note: a cremation risk certificate is not necessary if the cause of death certificate is not a Queensland cause of death
certificate and a cremation risk certificate has not been issued for the deceased person – section 6(4) and (5) of the
Cremations Act 2003.)
!
a certificate that authorises the release of the body given by a coroner, or person holding a position equivalent to
a coroner, at the place where the death happened.
Name, address and telephone number of person nominated to be sent the permission to cremate
(Section 6(9) of the Cremations Act
2003). (Complete only if this person is different from the applicant.):
Name:
Address:
Telephone number:
Signature of person making the application:
Date of application:
Note:
1.
The address for service is the address which will be used by the crematorium to give notice if it decides to bury any unclaimed
ashes after one year: section 11 of the Cremations Act 2003.
2.
The application can be sent to the coroner or independent doctor by fax or other electronic means: section 6(3) of the Cremations
Act 2003.
3.
The permission to cremate can be sent to the applicant, or person nominated by the applicant, by fax or other electronic means:
section 6(9) of the Cremations Act 2003.
4.
Section 16 of the Cremations Act 2003 makes it an offence to give false or misleading information in a material particular to a
coroner or independent doctor. The maximum penalty that can be imposed is 80 penalty units ($6000).
RESET FORM
Form 1 ver. 1 – 31/10/03
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