Victorian Consolidated Regulations Victorian Consolidated RegulationsFORM 1
Cemeteries and Crematoria Act 2003
Cemeteries and Crematoria Regulations 2015
APPLICATION FOR INTERMENT AUTHORISATION
The deceased
Full name:
Sex: *Male *Female
Date of birth:
Date of death:
Age:
Last known permanent address:
Religion if any (please note this field is optional):
Did the deceased have a spouse or domestic partner at the time of the deceased's death? *Yes *No
Details of interment
Name of cemetery:
Type of place of interment (e.g. grave, vault, crypt):
Location in cemetery of place of interment (e.g. grave number, section and row):
Please answer this question if this will be the first interment in the place of interment—how many additional interments will be required? (Please indicate which applies).
*0 *1 *2 *3 * Other
Dimensions of coffin, receptacle or container if any:
Length:
Width: Depth:
Material of which coffin, receptacle or container is constructed (e.g. wood, metal):
Applicant for interment authorisation
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Consent of holder of right of interment
Are you the holder of the right of interment for the place of interment where the remains will be interred? *Yes *No
If yes, proceed to "Other matters"
If no, provide the details of the holder of the right of interment, answer the questions below and where possible obtain the signature of the right of interment holder.
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Has the holder of the right of interment been informed of this application? *Yes *No
If no, give reasons why the holder of the right of interment has not been informed of this application:
If yes, does the holder of the right of interment consent to this application?
*Yes *No
If yes please obtain the holder's signature below.
Signature of holder of right of interment: Date:
Other matters
Details of the funeral director or the person otherwise arranging for the interment of the human remains:
*Company Name:
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Fax: Email:
Matters relating to interment
Service type:
*service both ends *meet at cemetery *no attendance
Location:
Date: Time:
Special service requirements:
Other remarks:
Details of the type of place of interment:
*new *pre-purchases/pre-need *reopen
Signature of applicant: Date:
WARNING
Under section 117 of the Cemeteries and Crematoria Act 2003 it is an offence to make a false statement in an application for an interment authorisation, punishable by a fine of up to 240 penalty units or 2 years imprisonment or both.
*Delete if not applicable
FORM 2
Cemeteries and Crematoria Act 2003
Cemeteries and Crematoria Regulations 2015
APPLICATION FOR INTERMENT APPROVAL FOR INTERMENT OTHER THAN IN A PUBLIC CEMETERY
The deceased
Title: Given Names: Surname:
Sex: *Male *Female
Date of birth:
Date of death:
Last known permanent address:
Suburb/Town: State: Post Code:
Applicant for interment approval
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Location of proposed interment
Interment location [ provide property details including address and Certificate of Title folio and volume reference, and if the interment is proposed to take place on Crown land, Crown allotment details ]:
Location of interment on land [ please provide details consistent with the cemetery system for recording grave locations, for example section, row and plot/grave number ]:
Details of other interments at the proposed place of interment
Is there a record of another person having been buried on the land?
*Yes
*No
If no, contact the department to discuss the application.
If yes, is the existing grave/s clearly marked? *Yes *No
Provide details, such as existing headstones, fencing of grave, etc.
Consent of land owner/manager
Is the land on which the interment is to take place:
*Crown land *Privately owned land
Please provide a statement from the applicable person listed below:
* landowner—attach a copy of the Certificate of Title confirming your ownership of the land and sign below indicating your consent to the interment on your land
Signature of landowner: Date:
* appointed delegate of the landowner—attach a copy of the Certificate of Title and a signed statement from the land owner indicating that you are authorised to act on their behalf in regards to conducting interments on their land. This statement must include the land owner's full name, address and contact telephone number.
* appointed land manager (relates to Crown land)—attach a statement from the body responsible for the management of that land that you are authorised to carry out the interment on the land.
Other matters
Details of funeral director or the person who otherwise arranged for the interment of the human remains:
*Company Name:
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Fax: Email:
Dimensions of coffin, receptacle or container if any:
Length: Width: Depth:
Material of which coffin, receptacle or container is constructed (e.g. wood or metal):
Description of memorial or marker to be placed over the place of interment:
Signature of applicant: Date:
WARNING
Under section 122 of the Cemeteries and Crematoria Act 2003 it is an offence to make a false statement in an application for an interment approval, punishable by a fine of up to 240 penalty units or 2 years imprisonment or both.
* Delete if not applicable
Sch. 1 Form 3 substituted by S.R. No. 71/2020 reg. 10.
FORM 3
Cemeteries and Crematoria Act 2003
Cemeteries and Crematoria Regulations 2015
APPLICATION FOR CREMATION AUTHORISATION FOR DECEASED PERSONS OF KNOWN IDENTITY
This form must always be accompanied by a Certificate of Registered Medical Practitioner Authorising Cremation (Form 4) unless the application relates to one of the following, in which case the form is not required:
• the cremation of a still-born child (please check the Medical Certificate of Cause of Perinatal Death form to confirm whether the application relates to a still-born child)
• where an order has been made by a Coroner under section 47 of the Coroners Act 2008
• a deceased person who died interstate or overseas and for whom an authority to cremate has been issued by the Coroner or other person permitted by the law of the jurisdiction where they died to authorise the cremation.
Name of crematorium at which cremation is to take place:
Details of deceased
Full name:
Sex: *Male *Female
Date of birth:
Date of death:
Age:
Last known permanent address:
Suburb/Town: State: Post Code:
Religion, if any (this information is optional):
Did the deceased have a spouse or domestic partner at the time of the deceased's death? *Yes *No
Applicant for cremation authorisation
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Cremated remains
Following cremation, the cremated remains are to be:
*Memorialised at:
*Collected by:
*Held at crematorium for up to 12 months after the cremation:
*Other [please specify]:
Please note that cemetery trusts are required to hold the cremated remains for at least 12 months after the cremation. Following the expiry of the 12 month period, the cemetery may dispose of the cremated remains in any way that it considers appropriate.
*If you would like to nominate an agent to collect the cremated remains provide the following details:
Agent details
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Matters relating to the cremation
Service type: *service both ends *meet at cemetery *no attendance
Location:
Date of cremation: Time:
Special service requirements:
Other remarks:
Statement by funeral director
This section should be filled out by the funeral director or the person who is otherwise arranging for the cremation of the human remains.
*Removal of pacemaker or other battery-powered device from the deceased is not required.
*I have arranged for any pacemaker or other battery-powered device referred to on the medical certificate of cause of death to be removed from the deceased as required by the relevant cemetery trust.
*Company name:
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Signature: Date:
WARNING
Under section 132 of the Cemeteries and Crematoria Act 2003 it is an offence to make a false statement in an application for a cremation authorisation, punishable by a fine of up to 600 penalty units or 5 years imprisonment or both.
I have read and understood all the information in this application.
Signature of applicant
Date:
* Delete if not applicable .
Sch. 1 Form 3A inserted by S.R. No. 71/2020 reg. 10.
FORM 3A
Cemeteries and Crematoria Act 2003
Cemeteries and Crematoria Regulations 2015
APPLICATION FOR CREMATION AUTHORISATION OF BODILY REMAINS OF UNKNOWN NAME OR WITH AN IDENTIFIER
This form must always be accompanied by an approval from the Secretary under section 134 of the Act.
Applicant for cremation authorisation
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Name and address of source of bodily remains
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Examples:
Examples of sources of bodily remains include schools of anatomy, body donor programs, universities, museums and body parts exhibitions.
Reference number of container holding bodily remains
Note:
A container reference number is assigned by the entity which is the source of the bodily remains, or the applicant for cremation authorisation. The container is to include a list of the identifiers assigned to the bodily remains in the container.
Note:
Regulation 26 prescribes the requirements for a container enclosing bodily remains and body parts, to be cremated in a public cemetery.
Identifier assigned to bodily remains
Note:
The identifier may be assigned by the entity which is the source of the bodily remains or the applicant for cremation authorisation.
Note:
The entity which is the source of the bodily remains should keep records of container reference numbers, identifiers and the date, name and address of the crematorium where the bodily remains are disposed.
Name and address of crematorium at which cremation is to take place
Name:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Cremated bodily remains
Following cremation, the cremated bodily remains are to be:
• interred
• other: [ please specify ]
Note:
For instance if the cremated bodily remains are scattered in a designated area in a public cemetery, this should be identifiable and possible to locate.
Statement by funeral director
This section should be filled out by the funeral director or the person who is otherwise arranging for the cremation of the bodily remains.
*Removal of pacemaker or other battery-powered device from the bodily remains is not required.
*I have arranged for any pacemaker or other battery-powered device to be removed from the bodily remains as required by the relevant cemetery trust.
*Company name:
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Signature: Date:
WARNING
Under section 132 of the Cemeteries and Crematoria Act 2003 it is an offence to make a false statement in an application for a cremation authorisation, punishable by a fine of up to 600 penalty units or 5 years imprisonment or both.
I have read and understood all the information in this application.
Signature of applicant
Date:
* Delete if not applicable .
Sch. 1 Form 3B inserted by S.R. No. 71/2020 reg. 10.
FORM 3B
Cemeteries and Crematoria Act 2003
Cemeteries and Crematoria Regulations 2015
APPLICATION FOR CREMATION AUTHORISATION OF BODY PARTS OF UNKNOWN NAME WITH AN IDENTIFIER
Applicant for cremation authorisation
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Name and address of source of body parts
Name:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Examples:
Examples of sources of body parts include schools of anatomy, body donor programs, universities, museums and body parts exhibitions.
Reference number of container holding body parts
Note:
A container reference number is assigned by the entity which is the source of the body parts, or the applicant for cremation authorisation. The container is to include a list of the identifiers assigned to the body parts contained in the container.
Note:
Regulation 26 prescribes the requirements for a container enclosing bodily remains and body parts, to be cremated in a public cemetery.
Identifier assigned to body parts
Note:
The identifier may be assigned by the entity which is the source of the body parts or by the applicant for cremation authorisation.
Note:
The entity which is the source of the body parts provides and keeps records of container reference numbers, identifiers and the date, name and address of the crematorium where the body parts are disposed.
Name and address of crematorium at which cremation is to take place
Name:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Cremated body parts
Following cremation, the cremated body parts are to be:
• interred
• other: [ please specify ]
Note:
For instance if the cremated body parts are scattered in a designated area in a public cemetery, this should be identifiable and possible to locate.
Statement by funeral director
This section should be filled out by the funeral director or the person who is otherwise arranging for the cremation of the human remains.
*Removal of pacemaker or other battery-powered device from the body parts is not required.
*I have arranged for any pacemaker or other battery-powered device to be removed from the body parts as required by the relevant cemetery trust.
*Company name:
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
I have read and understood all the information in this application.
Signature of applicant
Date:
* Delete if not applicable .
FORM 4
Cemeteries and Crematoria Act 2003
Cemeteries and Crematoria Regulations 2015
CERTIFICATE OF REGISTERED MEDICAL PRACTITIONER AUTHORISING CREMATION
Note 1:
In accordance with section 138 of the Cemeteries and Crematoria Act 2003 this form must be completed by a registered medical practitioner who is not the registered medical practitioner who completed the notice as required under section 37(2) of the Births, Deaths and Marriages Registration Act 1996 in respect of the death of the deceased person who is to be cremated.
Note 2:
This form is not required for the cremation of a still-born child. For all perinatal deaths, please check the Medical Certificate of Cause of Perinatal Death to confirm whether the application relates to a still-born child.
The deceased
Full name:
Sex: *Male *Female
Date of birth:
Date of death:
Place of death:
Certificate
I, [ name of registered medical practitioner ], of [ address of registered medical practitioner ], certify that:
1. I am a currently registered medical practitioner under the Health Practitioner Regulation National Law.
2. I have carefully read the statements contained in the Application for Cremation Authorisation relating to the deceased, signed by [ applicant for cremation authorisation ] and dated [ date of application for cremation authorisation ].
3. I have examined the body of the deceased.
4. I have sighted:
* a completed Medical Certificate of Cause of Death of a person aged 28 days or over prepared pursuant to section 37(2) of the Births, Deaths and Marriages Registration Act 1996 ; or
* a completed Medical Certificate of Cause of Perinatal Death prepared pursuant to section 37(2) of the Births, Deaths and Marriages Registration Act 1996 .
AND I state that:
1. I have made careful and independent inquiry into the circumstances surrounding the death of the deceased.
2. I agree with the cause of death as shown on the notice given under section 37(2) of the Births, Deaths and Marriages Registration Act 1996 .
3. In my opinion the death is not reportable or reviewable under the Coroners Act 2008 .
4. In my opinion, there is no circumstance concerning the death of the deceased that might necessitate further examination of the body before it is cremated, or which could, in my opinion, make exhumation of the body necessary at any time in the future.
5. In my opinion there is no reason why the cremation should not proceed.
6. Apart from any fee payable for the provision of this certificate, I have not acquired and do not anticipate acquiring directly or indirectly any property or pecuniary or other benefit of any description by reason of the death of the deceased.
7. I am not in partnership with, nor will I derive any professional remuneration from, any registered medical practitioner who professionally attended the deceased.
*I authorise the cremation of the deceased.
*I refuse to authorise the cremation of the deceased on the grounds that:
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile: Email:
Medical practitioner registration number:
Signature: Date:
Under section 140 of the Cemeteries and Crematoria Act 2003 it is an offence
to make a false statement in a certificate of a registered medical
practitioner authorising cremation, punishable by a fine of up to 600 penalty
units or 5 years imprisonment or both.
Sch. 1 Form 5 amended by S.R. No. 115/2015 reg. 6.
FORM 5
Cemeteries and Crematoria Act 2003
Cemeteries and Crematoria Regulations 2015
APPLICATION TO SECRETARY FOR EXHUMATION LICENCE
This application relates to the exhumation of the remains of (state details of deceased):
Details of deceased
Title: Given Names: Surname:
Sex: *Male *Female
Part A: Applicant for exhumation licence
Full name:
Address:
Telephone number:
Email:
Part B: Location of current interment
Name of cemetery [ for exhumations outside of a public cemetery also include both the property address and the Certificate of Title folio and volume reference or Crown allotment details ]:
Type of place of interment (e.g. grave, crypt):
Location of place of interment (e.g. grave number, row and section or description of the location):
Details of other interments at the place of interment:
Is there a memorial on the place of interment?
*Yes *No
Details of type of coffin, container or receptacle used (if known):
Was the body embalmed and to what degree (if known):
Attach a statement from the cemetery trust, land owner or land manager stating:
• whether there are any reasons why the exhumation cannot be accommodated at this time; and
• for public cemeteries only, the name of the current holder of the right of interment as recorded in the cemetery trust records.
*Statement attached:
Part C: Disposition of the remains after exhumation
What will happen to the remains after exhumation [ select one option only ]:
*Re-interred in a grave/vault/crypt [ select the type of site that applies ] at [ state name of cemetery ]:
*Cremated in Victoria at [ state name of crematorium ]:
*Transportation interstate
*Transportation overseas.
Part D: Details of funeral director or other person engaged to assist at the exhumation
*Company name:
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Fax: Email:
Part E: Consent of holder of right of interment for the place of interment from which the remains are to be exhumed
If the remains are to be exhumed from a place of interment in a public cemetery , the holder of the right of interment must complete this section.
If the remains are not being exhumed from a public cemetery, proceed to Part F .
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile: Email:
Do you consent to this application? *Yes *No
Signature: Date:
Part F: Consent of holder of right of interment for the proposed place of re-interment
If the remains are to be re-interred in a public cemetery , the holder of the right of interment must complete this section.
If the remains are not being reinterred in a public cemetery, proceed to Part G.
Title: Given Names Surname
Address:
Suburb/Town State Post Code
Telephone: Home Work Mobile
Do you consent to the re-interment application? *Yes *No
Signature of holder of right of interment for new place of interment:
Signature: Date:
Part G: Consent of nearest surviving relative/s of the deceased
Indicate below only the first listed category in which there is a nearest surviving relative of the deceased:
*spouse or domestic partner of the deceased at the time of their death
*son or daughter or stepson or stepdaughter who has attained the age of
18 years
*father or mother
*brother or sister who has attained the age of 18 years
*grandfather or grandmother
*grandson or granddaughter who has attained the age of 18 years
*uncle or aunt who has attained the age of 18 years
*nephew or niece who has attained the age of 18 years
Provide below the details and consents of all nearest surviving relatives of the deceased in the indicated first category. Attach additional pages if required.
Title: Given Names: Surname:
I consent to the exhumation of the remains of the deceased.
Signature: Date:
Are there any other nearest surviving relatives of the deceased in the
indicated first category whose details and consent have not been provided
above?
*Yes *No
If Yes , give details of any nearest surviving relatives in the indicated category who have not given consent and reasons why the consent of these relatives has not been obtained.
Title: Given Names: Surname:
Relationship to the deceased:
Reasons why the consent of this relative has not been obtained:
Declaration by applicant
I declare that:
• all of the deceased's surviving parents, children (who have attained the age of 18 years, including stepchildren) and siblings (who have attained the age of 18 years) have been informed of the proposed exhumation and have no objection; and
• any parent or guardian of any minor child (including stepchild) or minor sibling of the deceased has been informed of the proposed exhumation and has no objection; and
• I am not aware of any objection to the proposed exhumation from any other surviving relatives of the deceased, including but not limited to grandparents, grandchildren (who have attained the age of 18 years), uncles and aunts (who have attained the age of 18 years) and nephews and nieces (who have attained the age of 18 years).
Signature of applicant: _________________ Date: _____.
If you are not able to make the above declaration because a surviving relative has not been informed or has an objection, please provide a detailed explanation of the circumstances in a separate statutory declaration.
Part H: Details of executor of the deceased's estate
Did the deceased leave a will? *Yes *No
If the executor is a natural person (i.e. not a company or other body corporate), is the executor alive? *Yes *No
To be completed by the executor of the deceased's estate:
Title: Given Names: Surname:
Address:
Suburb/Town: State: Post Code:
Telephone: Home: Work: Mobile:
Email:
Does the will or any other document contain instructions as to the disposal of the remains of the deceased?
*Yes *No
If yes, provide evidence and attach copies of any relevant documentation.
Documents attached? *Yes *No
Signature of executor: Date:
Declaration by applicant
Under section 158A of the Cemeteries and Crematoria Act 2003 it is an offence to make a false statement in an application for exhumation licence, punishable by a fine of up to 240 penalty units or 2 years imprisonment or both.
All information I have provided on this form is correct. I understand that it is an offence to knowingly make a false statement in an application for exhumation licence.
Signature of applicant: Date:
* Delete if not applicable