New Zealand Legislation: Regulations

Form A
The Cremation Regulations 1973

Consecutive number [to be inserted on receipt of application] I, [Full name of applicant], [Address], [Occupation], apply to the crematorium authority of the Crematorium (or as the case may be) to undertake the cremation of the body of [Full name of deceased], [Address], [Occupation], [Age], [Sex], [Whether married, widow, widower, or unmarried]. The true answers to the questions set out below are as follows: 1. 1. Are you an executor of the deceased? 2. Are you a relative of the deceased? If so, state the relationship If you are not an executor or a near relative*, state why this application is being made by you and not by an executor or a near relative*: 3. Have the near relatives* of the deceased been informed of the proposed cremation? 4. If the application is not made by an executor, is there an executor of the deceased? If there is an executor has he been informed of the proposed cremation? 5. To the best of your knowledge and belief has any near relative or executor of the deceased expressed any objection to the proposed cremation? If so, on what ground? 6. What, to the best of your knowledge and belief, was the date and hour of the death of the deceased? Date: Hour: 7. Where did the deceased die? [Give address, and say whether own residence, lodgings, hotel, hospital, nursing-home, etc.] 8. Do you know or have you any reason to suspect that the death of the deceased was due, directly or indirectly, to— (a) Violence: (b) Poison: (c) Privation or neglect: (d) Illegal operation? 9. Do you know any reason whatever for supposing that an examination of the body of the deceased may be desirable? 9A. Do you know or have you any reason to suspect that the body of the deceased contains a cardiac pacemaker or other biomechanical aid? 10. Give the name and address of the ordinary medical attendant of the deceased: 11. Give the names and addresses of all the medical practitioners who attended the deceased during his (or her) last illness: 12. Who were the persons (if any) present at the time of death?

13. Was the deceased a member of a religious denomination whose tenets require the burning of the body to be carried out as a religious rite elsewhere than in an approved crematorium? If so, give the name by which that religious denomination is known I hereby certify, with a view to procuring the cremation of the body of the abovenamed deceased, that all the particulars stated above are true, and that to the best of my knowledge and belief no material particular has been omitted. Date: Signature: Witness to signature: Name: Occupation: Address: *NOTE—The term near relative as used in this form means the wife or husband of the deceased, a parent of the deceased, or a child of the deceased who is of or over the age of 16 years; and includes any other relative of the deceased who usually resided with him.

• Form A, Question 9A was inserted, as from 1 November 1980, by regulation 5 Cremation Regulations 1973, Amendment No 1 (SR 1980/208).

• Form A was amended, as from 26 April 2005, by section 12 Relationships (Statutory References) Act 2005 (2005 No 3) by substituting the words “relationship status, ie, whether the deceased was or had been married, in a civil union, or in a de facto relationship; or was the surviving spouse or partner of a marriage, civil union, or de facto relationship; or had never been married, in a civil union, or in a de facto relationship” for the words “Whether married, widow, widower, or unmarried”.

• Form A was amended, as from 26 April 2005, by section 12 Relationships (Statutory References) Act 2005 (2005 No 3) by substituting all the words in the note after the words “The term ‘near relative’ as used in this form, means”.

I HEREBY certify that I have examined the body of [Full name], [Address], [Occupation]. * I am satisfied that the body does not contain a cardiac pacemaker or any other biomechanical aid. *I have removed from the body a cardiac pacemaker or other biomechanical aid, namely Signature: Address: Date: Registered Qualifications: * Delete whichever is inapplicable.

• Schedule 1, form AB was inserted, as from 1 November 1980, by regulation 6 Cremation Regulations 1973, Amendment No 1 (SR 1980/208).

• Schedule 1 form AB heading: amended, on 20 November 2008, by regulation 7 of the Cremation Amendment Regulations 2008 (SR 2008/410).

I AM informed that application is about to be made for the cremation of the body of [Full name of deceased], [Address], [Occupation].

As a medical practitioner who is required or permitted by section 46B or 46C(1) of the Burial and Cremation Act 1964 to give a doctor’s certificate (as defined in section 2(1) of that Act) for the death, and who has seen and identified the body after death, I give the following answers to the questions set out below:

• 1. On what date and at what hour did he (or she) die? ...

• 2. Where did the deceased die? [Give address and say whether own residence, lodgings, hotel, hospital, nursing-home, etc]

• 3. Are you a relative of the deceased? ... If so, state the relationship. ...

• 4. Have you, so far as you are aware, any pecuniary interest in the death of the deceased? ...

• 5. Were you the ordinary medical attendant of the deceased? ... If so, for how long? [State how many weeks, months, or years.]

• 6. Did you attend the deceased during his (or her) last illness? ... If so, for how long? [State how many hours, days, weeks, or months.]

• 7. If you attended the deceased during his or her last illness, when did you last see the deceased alive? [Say how many hours or days before death.]

• 8. 

  • (a) How soon after death did you see the body? ...

  • (b) What steps did you take to satisfy yourself as to the fact of death? ...

  • (c) How did you establish the identity of the deceased person? ...

• 9. 

  What were the causes of death?		Period elapsing between onset of each condition and death (years, months, or days).
  (a)	Immediate cause—the disease, injury, or complication which caused death?.............	...................................................................
  (b)	Morbid conditions (if any) giving rise to the immediate cause (place the conditions in chronological order beginning with the most recent)?.............	...................................................................
  (c)	Other conditions (if any) contributing to death—pregnancy, parturition, over-exertion, dangerous occupation?.............	...................................................................

State how far your answers as to the causes of death and the duration of such causes are founded on your own observations or on statements made by others. If on statements made by others, give their names and their relationship to the deceased ...

• 10. What was the mode of death? [Say whether syncope, coma, exhaustion, convulsions, etc] ... What was its duration? [State number of days, hours, or minutes; and state how far your answer as to the mode of death is founded on your own observations or on statements made by others. If on statements made by others, give their names and their relationship to the deceased.]

• 11. Did the deceased undergo any operation during the final illness or within a year before death; if so, what was its nature, and who performed it? ...

• 12. By whom was the deceased nursed during his (or her) last illness? [If the death occurred in a hospital, this question may be answered by referring generally to the nursing staff in a specified ward, but otherwise give names and say whether professional nurse, relative, etc. If the illness was a long one, this question should be answered with reference to the period of four weeks before death.]

• 13. By what medical attendants (besides yourself, if applicable) was the deceased attended during his (or her) last illness? ...

• 14. In view of the knowledge of the deceased's habits and constitution, do you feel any doubt whatever as to the character of the disease or the cause of death? ...

• 15. Do you know, or have you any reason to suspect, that the death of the deceased was due, directly or indirectly, to—

  • (a) Violence: ...

  • (b) Poison: ...

  • (c) Privation or neglect: ...

  • (d) Illegal operation: ...

• 16. Have you any reason whatever to suppose a further examination of the body to be desirable? ...

• 17. Have you given the doctor’s certificate (as defined in section 2(1) of the Burial and Cremation Act 1964) for the death? ...

I hereby certify that the answers given above are true and accurate to the best of my knowledge and belief, and that there is no circumstance known to me which can give rise to any suspicion that the death was due wholly or in part to any other cause than disease (or accident) or which makes it desirable that the body should not be cremated.

NOTE—This certificate must be handed or sent in a closed envelope by the medical practitioner who signs it to a Medical Referee.

• Schedule 1 form B: amended, on 25 January 2009, by regulation 8(2)(a) of the Cremation Amendment Regulations 2008 (SR 2008/410).

• Schedule 1 form B: amended, on 25 January 2009, by regulation 8(2)(b) of the Cremation Amendment Regulations 2008 (SR 2008/410).

• Schedule 1 form B: amended, on 20 November 2008, by regulation 8(1)(a) of the Cremation Amendment Regulations 2008 (SR 2008/410).

• Schedule 1 form B: amended, on 20 November 2008, by regulation 8(1)(b) of the Cremation Amendment Regulations 2008 (SR 2008/410).

• Schedule 1 form B: amended, on 20 November 2008, by regulation 8(1)(c) of the Cremation Amendment Regulations 2008 (SR 2008/410).

• Schedule 1 form B: amended, on 20 November 2008, by regulation 8(1)(d) of the Cremation Amendment Regulations 2008 (SR 2008/410).

• Schedule 1 form B: amended, on 20 November 2008, by regulation 8(1)(e) of the Cremation Amendment Regulations 2008 (SR 2008/410).

Regulation 7(1)(b), Cremation Regulations 1973

• (a) a death has been reported under the Coroners Act 2006 to a coroner, and the details of the death are as follows:

• Full name of deceased:

• Late of: [full residential address]

• Occupation:

• Sex: [male or female]

• Date of birth:

• Date of death:

• Place of death:

• (b) I am satisfied that there are no circumstances likely to call for an examination or, as the case may be, a further examination, of the body.

• Schedule 1 form C: substituted, on 20 November 2008, by regulation 9 of the Cremation Amendment Regulations 2008 (SR 2008/410).

[Revoked]

• Schedule 1 form D: revoked, on 20 November 2008, by regulation 10 of the Cremation Amendment Regulations 2008 (SR 2008/410).

I HEREBY certify that, acting under the instructions of * ..., a Medical Referee under the Cremation Regulations 1973, I made a post-mortem examination of the body of [Full name], [Address], [Occupation]

The result of the examination is as follows:

I am satisfied that the cause of death was...(and that there is no reason for making any toxicological analysis or for reporting the death to the Coroner).†

* Where the Medical Referee himself gives the certificate, strike out the words “on the instructions of” and insert “as”.

† The words “for making any toxicological analysis or” should be deleted where a toxicological analysis has been made and its result is stated in this certificate or in a certificate attached to it, and the words “or for reporting the death to the Coroner” should be deleted if the death has already been so reported.

WHEREAS application has been made for the cremation of the body of [Full name], [Address], [Occupation]

And whereas I have satisfied myself—

• 1. That all the requirements of the Burial and Cremation Act 1964 and the Cremation Regulations 1973 have been complied with; and

• 2. * That the cause of death has been definitely ascertained (or that a Certificate in form C has been given by a Coroner); and

• 3. That no reason exists for any further inquiry or examination:

  Now, therefore, I hereby permit the cremation authority of the crematorium at ... to cremate the said body.

NOTE—

• 1. Delete all inappropriate alternatives in both places where an asterisk appears.

• 2. This permission should be signed in duplicate; one copy to be retained with the application papers and the other sent by the Medical Referee to the attendant at the crematorium. The Medical Referee should attach to the application papers a statement of any special inquiries which he may have seen fit to make before issuing the permission to cremate.

WHEREAS application has been made for the cremation of the body of [Full name], [Address], [Occupation]:

And whereas I have satisfied myself—

• 1. That all the requirements of the Burial and Cremation Act 1964 and the Cremation Regulations 1973 have been complied with; and

• 2. *That the cause of death has been definitely ascertained (or that the child was still-born or that a certificate in form C has been given by a Coroner); and

• 3. That no reason exists for any further inquiry or examination:

And whereas it has been represented to me that the said deceased belonged to a religious denomination whose tenets require the burning of the body to be carried out as a religious rite elsewhere than in an approved crematorium:

Now, therefore, I hereby permit the body of the said deceased to be cremated at ... subject to the following conditions:

NOTE—

1. Delete all inappropriate alternatives where the asterisk appears.

2. This permission should be signed in duplicate; one copy to be retained with the application papers and the other delivered to the person or persons signing the application.

Full name of deceased .............

Sex .............

Age .............

Date of Death .............

Place of death .............

Date of Medical Referee's permission or other authority .............

Date of Cremation .............

Method of disposal of ashes .............

Date of disposal of ashes .............

Signature of person receiving ashes .............

Ground of recipient's claim. (ie Applicant for cremation; relative of deceased—relationship to be stated, etc)