Western Australian Repealed Regulations Western Australian Repealed RegulationsThis legislation has been repealed.
Form No. 1
Western Australia
( Registration of Births, Deaths and Marriages Act 1961 )
BIRTH INFORMATION PAPER
Item 1
Regn. Number.................
(IMPORTANT — Handwriting on this paper should he done with a
black or blue-black iron-gall ink of GOOD PERMANENCE.)
|
Item | |
|
Child |
2. (1) Date of Birth
(in words NOT figures)...................day of ....................19........
|
|
(2) Place of Birth
(Precise Address
required)..................................................... | |
| |
(3) Name of Child
(block letters): |
| |
Full Christian Names
........................................................................ |
| |
or equivalent) |
| |
Surname.........................................................................................
|
|
If twins or triplets, state whether “1st
born,” and “2nd born,” etc......................... | |
| |
(4)
Sex..........Weight of Child at Birth...................grammes |
| |
Was child born alive...............If not, state
period of gestation. |
|
Father |
3. (1) Name of Father
(block letters): |
|
of Child |
Full Christian Names
............................................................................ |
|
(or equivalent) Surname
...........................................................................................
| |
|
(2) Usual
Occupation...................... (3) Age (last
Birthday)............................. | |
| |
(4) Birthplace
(Town).......................(State and/or
Country).............................. |
|
Marriage |
4. (1) Date of
Marriage. . . . . . . . . . . . . . . . . . . . . 19. . . . . . . . (2) Place of Marriage
(Town, State and/or Country). . . . . . . . . . . . . . . . . . . . (3) Previous Issue of above Marriage (including
children legitimated thereby) in order of Birth. (Please state full Christian
(or equivalent) Names of both living and deceased Children. In the case of
deceased Issue, enter the word “Deceased” in lieu of Age. If
unnamed, so describe, and state sex): — |
|
Christian or |
Age Last |
Christian or |
Age Last |
|
Other Issue of Mother (i.e., any Children NOT of present
Marriage) — | |
| |
No. of Males.........................No. of
Females............................ |
|
Mother |
5. (1) Name of Mother
(block letters): Full Christian Names (or
equivalent)........................................................ |
| |
Surname when Child was Born...................(2)
Maiden Surname.................. |
| |
(3) Age (last
Birthday).............................................................................
|
|
(4) Birthplace (Town)
.......................(State and/or Country) ........................... | |
|
|
Name of Municipality in which Mother usually
resides.................................. (City/Town/Shire) (Strike out whichever is
inapplicable.) |
|
Witnesses |
6. (1) Name of
Accoucheur (Doctor or Midwife)................................................
(2) Name of
Nurse.................................................................................
|
|
(3) Names of other
Witnesses of Birth.......................................................... |
|
|
(4) Name of Occupier
of Place where Child was Born....................................... | |
| |
DECLARATION BY INFORMANT |
|
Informant |
7. (3) I, the
undersigned, (name in full)
............................................................ (2) Residing at (full
address)..................................................................... (1) being the (see Footnote
(a))...................................of the Child mentioned in Item 2 above
do solemnly and sincerely declare that the particulars given in this Paper are
true to the best of my knowledge and belief. And I make this solemn
declaration knowing that by the Criminal Code I am liable, in case of
falsehood, to imprisonment with hard labour for three years. |
|
To Sign |
Signature of
Informant.......................................................................
Declared
at..........................this.....................day
of.........................19........ Before me (Signature of
Witness)..............................................(if practicable one of
the persons mentioned in Item 6 above should sign as Witness) of (Address of
Witness)..............................................................................................
|
|
Received by Assistant D.R.
at.............................on ...........................19........ | |
| |
Signature of Assistant District Registrar
.......................................................... |
| |
Received by District Registrar at
.........................on ...........................19........ |
| |
Signature of District
Registrar......................................................................
|
|
Registrar |
8. (1) Registered
on............................19........................(2) at Perth. |
| |
(3) Signature of
Registration Officer
............................................................ |
| |
(a) Here state “Father” or
“Mother”. If impracticable for Father or Mother to act as
Informant, “Occupier of place of birth” should be the Informant. |
Form No. 2
Western Australia
( Registration of Births, Deaths and Marriages Act 1961 )
DEATH INFORMATION PAPER
Item 1
Regn. Number.................
(IMPORTANT — Handwriting on this paper should be done with a
black or blue-black iron-gall ink of GOOD PERMANENCE.)
|
Deceased Person |
2. (1) Name (Block
{ Full Christian Names (or | |||||
| |
(2) Usual
Occupation..............................................................................
| |||||
|
(3) Late Residence
(usual address)...............................................................
| ||||||
|
In............................City, Town, Shire
(strike-out whichever is inapplicable). | ||||||
| |
(4)
Sex.........................Age.................................. | |||||
| |
3. (1) Date of Death
..............................day
of................................19......... | |||||
| |
(2) Place of Death
(precise address required).................................................. |
|||||
|
4. (1) Cause of
Death — For details see { Medical
Certificate attached. | ||||||
inapplicable).
Coroner.
(2) Medical
Practitioner by whom
certified....................................................
(3) Date he last saw
Deceased alive.............................................................
5. (1) Birthplace
(town and
country)...............................................................
(2) Years lived in
each Australian State (to be named).......................................
6. (1) Father’s
Name { Full Christian Names (or
equivalent)...........................
(Block letters)
{
Surname.............................................................
(2) Father’s
usual occupation
.....................................................................
(3) Mother’s
Name { Full Christian Names (or
equivalent)...........................
(Block letters) {
Maiden Surname..................................................
7. (1) State whether
deceased was Single, Married, Widowed or Divorced..................
Details of First Marriage
Details of Subsequent Marriages
(2) Place ..........................
................................................
(3) Date...........................
................................................
(4) To whom .....................
...............................................
(5) Names and ages of children of deceased in
order of birth. (Please state full christian (or equivalent) Dames of both
living and deceased children. In the case of deceased children, enter the word
“Deceased” in lieu of age. If unnamed, so describe, and state
sex): —
Christian (or
equivalent)
names only
Age last
Birthday,or
“Deceased”
Christian (or
equivalent)
Names only
Age Last
Birthday,
or “Deceased”
|
Was deceased in receipt of (state Yes or No): — (a) Age or
Invalid Pension....................... (b) Widow’s Pension .....................(c) Child
Endowment....................................... (d) War
Pension.............................................................................................
| |
|
Disposal of Body |
8. (1) Date of Burial
or Cremation (state which) ................................................ (2) Place of Burial or
Cremation ...........................Portion of ........................ |
| |
Cemetery; or
Crematorium at................................................................
|
|
(3) Name of person who
certified to disposal of body........................................ | |
| |
(4) Name of certifying
crematorium official................................................... |
| |
(5) Officiating
Minister’s
Name.................................................................. |
| |
(6) Religious
Denomination......................................................................
|
|
(7) Names of Witnesses
to Burial or depositing of body at Crematorium | |
| |
DECLARATION BY INFORMANT |
|
Informant |
9. (3) I, the
undersigned, (name in
full)............................................................ |
| |
(2) of (full address)
................................................................................
|
|
(1) (description — see Footnote
(a))...................................... being one of the persons required
by law to give information to the District Registrar concerning the death of
the abovementioned deceased person, do solemnly and sincerely declare that the
particulars given in this paper are true to the best of my knowledge and
belief. And I make this solemn declaration knowing that by the Criminal Code I
am liable, in case of falsehood, to imprisonment with hard labour for three
years. | |
|
To Sign |
Signature of
Informant........................................................................
|
|
Witness to |
Declared at.....................
this.....................day of....................19........ Before me (Signature of Witness)
.......................................................... |
| |
of (Address of
Witness)......................................................................
|
|
Received by Assistant D.R. at
......................on.........................19........ | |
| |
Signature of Assistant District Registrar
................................................ |
| |
Received by District Registrar at
..................on............................19........ |
| |
Signature of District Registrar
.............................................................. |
|
Registrar |
10. (1) Registered
on...................................19..........(2) at Perth. |
| |
(3) Signature of
Registration Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. |
(a) The informant must be either the “Person
disposing of the Body” or the “Occupier of the Place”
wherein the death occurred, e.g., Funeral Director, Matron of Hospital, etc.
Form No. 3
RECORD OF BIRTH AND DEATH INFORMATION PAPERS
RECEIVED BY THE ASSISTANT DISTRICT REGISTRAR.....................
|
Date |
Birth or |
Date of |
Place of |
Name of |
Name of Informant |
Address of Informant |
Posted to District Registrar |
|
|
FORM No. 4
Registration of Births, Deaths and Marriages Act 1961 .
ADOPTION
INFORMATION CARD FOR RE- REGISTRATION OF BIRTH
(Pursuant to Section 13 of Adoption of Children Act 1896 )
No...................................
The Child was born on the.......................day of.......................,
19........
At.............................................................................................
Full Christian Name and Surname of
Child.............................................
(Block letters)
................................................................................................
Sex of
child..................................................................................
Full christian Name and Surname of Adopting
Father.................................
................................................................................................
Full Christian Name and Surname of Adopting
Mother..............................
Address of Residence of Adopting
Parents.............................................
Date and Number of Order of
Adoption.................................................
Address of
Applicant.......................................................................
................................................................................................
Date of
Application........................................................................
Full Name of Applicant (to be subscribed by
Applicant).............................
Date and Place of
Registration...........................................................
Signature and Title of
Registrar..........................................................
Form No. 5
BIRTH IN THE STATE OF WESTERN AUSTRALIA
REGISTERED BY..................................
|
Column 1. |
REGISTRATION NUMBER |
|
2. |
CHILD |
| |
|
When and where Born
Christian Name and
Surname
Sex
3.
PARENTS
Name of Father
Name of Mother
Address of Residence
4.
When and Where
Registered
Signature and Title of
Registrar
Form No. 6
Western Australia
Registration of Births, Deaths and Marriages Act 1961
CHANGE OR ASSUMPTION OF NAME
Any person whose birth or marriage is registered in Western Australia, and who
has lawfully changed his or her name or has lawfully assumed a name since such
registration, may apply to the REGISTRAR GENERAL to have an entry referring to
such change or assumption of name made in either or both of the registers of
births and marriages.
Any person to whom this provision applies is urged to take advantage of it
without delay by forwarding to the Registrar General, Perth, the
following: —
1. The subjoined application form duly completed
and supported by,
a. The License or Deed Poll duly registered by the
Registrar of Deeds
or
b. A certified copy of either document, issued by
the Registrar of Deeds
or
if the lawful assumption of name occurred by usage
c. Documentary evidence thereof or a Statutory
Declaration to that effect.
2. A fee of $1.00 for each entry.
Note: Change of or assumption of a surname by a
woman on or after marriage cannot be entered in her birth registration.
(Address).........................................
(Date)............................
THE REGISTRAR GENERAL,
Cathedral Avenue, PERTH, W.A.
Sir,
Whereas
(a)..............................................................................
(See footnote)
has lawfully assumed the name
of........................................................
................................................................................................
I now request that an entry referring to such change or assumption of name be
made in the margin of the Registration of
{ I. the birth of the said
(a)......................................................
{ who was born on
at.............................
{ and whose parents’ names were
(father)..................................
*{ and
(mother)..................................................................
{ II. the marriage of the said
(a).................................................
{ who was married
to.........................................................
{ at
on........................................
The fee of...................................is enclosed (see Note 2 in
instructions above) together with the Deed Poll, License, Statutory
Declaration. (Cross out whichever is inapplicable.)
Yours faithfully,
.................................................
Signature of Applicant
Note: (a)
Here state name in full prior to assumption of new name.
|
FOR OFFICE USE ONLY | |
|
{ If entry required on |
Registration No................................... Receipt No. and Date................................ |
|
*{If entry required on |
Entered by and Date................................. Indexed to year...................by.................. |
|
{ If entry required on |
Date D.R. advised................................... Checked by and Date ............................... |
Form No. 7
Western Australia
Registration of Births, Deaths and Marriages Act 1961
FOR OFFICE USE ONLY
Registration No...................................
Receipt
No. and Date...........................
Entered by and
Date............................
Indexed to
Year..................by...................
Date D.R.
Advised.............................
Checked by and
Date...............................
DECLARATION
I,
..........................................................................................of
.................................................................................employed
as
.................................................................do solemnly
and sincerely
(state usual occupation)
declare that: —
1. I was born
at.............................on........................................
2. I am the father of a child
named.................................................
........................................................................................
born
to...............................................................................
on the................................day
of..............................19........
at.......................................................................................
3. I desire that the relevant particulars relating
to me as the father of the said child be entered in the registration of the
birth of the child.
And I make this solemn declaration by virtue of Section 106 of the
Evidence Act 1906 .
Signature......................................................
Declared at.............................this...................day
of........................
19........before me
...........................................J.P.*
(or as the case may be)
DECLARATION TO BE MADE BY MOTHER IF BIRTH OF CHILD PREVIOUSLY REGISTERED
I,
.............................................................................................
of ..................................................................the
mother of the child
................................................................................................
solemnly and sincerely declare that I desire the relevant particulars relating
to
................................................................................................
who is the father of the said child, be entered in the registration of the
birth of the Child.
And I make this solemn declaration by virtue of Section 106 of the
Evidence Act 1906 .
...............................................
Declared before me at...............this..............day
of...................19........
................................................J.P.
*
(or as the case
may be)
* This Declaration may be made before any of the following persons: Justice of
the Peace, Town Clerk, Secretary to a Shire, Electoral Registrar, Postmaster,
Classified Officer in the State or Commonwealth Public Service, Classified
State School Teacher, or a member of the Police Force.
Form No. 8
Western Australia
Registration of Births, Deaths and Marriages Act 1961
APPLICATION UNDER SECTION 52 TO REGISTER THE BIRTH OF A LEGITIMATED CHILD
DOMICILED IN BUT NOT BORN IN WESTERN AUSTRALIA
To the REGISTRAR GENERAL.
1.
I/We..................................................................................
of.........................................................the mother of the
child
being
*...................................of...........................................
(child’s full name)
.........................................................................................
who is domiciled in the State of Western Australia
and who was born at
.........................................................................................
on..........................................and
who has been legitimated by our marriage at
.................................on.......................................
pursuant to Section...........................of
the Marriage Act 1961 , of the Parliament of the Commonwealth, hereby
apply to have the birth of the
said....................................................................................
registered pursuant to Section 52 of the
Registration of Births, Deaths and Marriages Act 1961 .
2. The birth of the
said................................................................
..........................was previously
registered at..............................
(If not previously registered, state why
not.)....................................
.........................................................................................
3. I/We attach the following
documents: —
(strike out any not applicable)
A. Certified Copy of the registration of the birth
of........................
.................................................................................
B. Certified Copy of the Registration of our
marriage.
C. Statement as to father’s domicile at time
of marriage.
D. A prescribed Birth Information Paper duly
completed.
E. A statutory declaration of paternity by the
father of....................
.................................................................................
F. Order of a Court under Section 92 of the
Marriage Act 1961 , of the Parliament of the Commonwealth.
*
Description of applicant, e.g., Parents, Father, Mother, Guardian, etc.
(Signature).............................................
FOR OFFICE USE ONLY
Registration No ...........................................
Receipt No. and Date.....................................
Entered by and Date......................................
Indexed to Year.....................by....................
Date D.R. Advised........................................
Checked by and Date.....................................
Form No. 9
Western Australia
Registration of Births, Deaths and Marriages Act 1961
(Part VI, Section 53)
Declaration
I,
(1)..........................................................................................
of (2).....................................,
(3)................................................
do solemnly and sincerely declare that: —
1. I am the father of a child
named.................................................
................................................................................................
born on the....................................day
of............................19........
at..............................................................................................
2. I was married
to.....................................................................
the mother of the said child on the.......................day of
......................... 19........,
at..................................................................................
and am desirous of having the birth of the said child registered as the lawful
issue of myself and the
said...............................................................
And I make this solemn declaration by virtue of section one hundred and
six of the Evidence Act 1906 .
Signature................................................
Declared at.........................the......................day
of.........................
19......., before me
..........................................J.P.*
(or as the case may be)
(1) Name in full
(2) Address
(3) Occupation
* This Declaration may be made before any of the
following persons: — Justice of the Peace, Town Clerk,
Secretary to a Shire, Electoral Registrar. Post-master, Classified Officer in
the State or Commonwealth Public Service, Classified State School Teacher, or
a member of the Police Force.
Form No. 10
Western Australia
Registration of Births, Deaths and Marriages Act 1961
APPLICATION UNDER SECTION 55 TO REGISTER THE BIRTH OF A LEGITIMATED PERSON
BORN IN WESTERN AUSTRALIA
To the REGISTRAR GENERAL.
1.
I,.....................................................................................
of....................................................................................
(usual address)
apply, pursuant to Section 55 of the
Registration of Births, Deaths and Marriages Act 1961 , for registration
of the birth of............................
.........................................................................................
who was born
at...........................on.......................................
(..............................(parents’
the..................of (
full
(son, daughter)
(.................................names)
and who was by virtue of Section.......................of the Marriage
Act 1961 , of the Parliament of the Commonwealth, legitimated by the
marriage of the said parents
at........................on..........................
2. I attach the following
documents: —
(strike out any not applicable)
A. Certified Copy of the registration of birth
of............................
..................................................................................
B. Certified Copy of the registration of the
marriage of the said parents.
C. A prescribed Birth Information Paper duly
completed.
D. Other evidence of legitimacy
(specify).................................
E. An Order made under Section 92 of the
Marriage Act 1961 , of the Parliament of the Commonwealth.
Date.............................
Signature........................
FOR OFFICE USE ONLY
Registration No ......................................
Receipt No. and Date................................
Entered by and Date.................................
Indexed to Year................by...................
Date D.R. Advised..................................
Checked by and Date ..............................
Registration of Births, Deaths and Marriges Act 1961
Form No. 11
Section 21A (2)
Regulation 16A
Western Australia
REQUEST BY MOTHER AND FATHER UNDER
SECTION 21A (2) — SURNAME
OF CHILD
Please read the Notes at the bottom of the page before completing this form.
We.............................................................................................
(Full names, addresses and occupations of mother and father)
parents of
....................................................................................
(Given or first name of the child)
who was born
on............................at.................................in Western
Australia, request the Registrar General to enter in the register the surname
of this child
as..................................................................................
Dated this.................................day
of................................, 19........
at.....................................................................
Signature of:
Father..................
Witness...........................
Address...........................
Mother..................
Witness...........................
Address...........................
Note:
(1) This form is only to be completed where it is
intended that the child be given a surname different from that of the father.
(2) The surname of a child, if not the same as
that of the father may, be —
(a) the surname of the mother, if the Registrar
General is satisfied that she has a surname that is different from the surname
of the father; or
(b) the surname of both parents, where the parents
have different surnames.
(3) Subject to Sections 21A (3) and (5) which
relate to traditional naming by ethnic groups, all children of the same mother
and father whose births are registered in Western Australia shall bear the
same surname.
Registration of Births, Deaths and Marriages Act 1961
Form No. 12
Section 21A (3)
Regulation 16B
Western Australia
REQUEST UNDER SECTION 21A(3) TO ENTER IN REGISTER A SURNAME GIVEN IN
ACCORDANCE WITH A RECOGNISED RELIGIOUS CUSTOM OR NAMING PROCEDURE
Please read the Notes at the bottom of this page before completing this form.
We.............................................................................................
(Full names, addresses and occupations of mother and father)
parents
of....................................................................................
(Full name of the child)
who was born on..............................at............................in
Western Australia, hereby request the Registrar General to enter in the
register.............
.........................as the surname of our child, and hereby declare
that —
1. The surname of
...................................................................
is a name selected in accordance with the
recognised religious custom or naming procedure
of................................................................
.........................................................................................
(Name or description of ethnic group)
2. *Both of us are members of that ethnic group.
* I.............................................am
a member of that ethnic group.
(name)
3. We agree to this application.
Dated this.................................day
of................................, 19........
at.....................................................................
Signature of:
Father..................
Witness...........................
Address...........................
Mother..................
Witness...........................
Address...........................
Note:
(1) The Registrar General may only enter as the
surname of a child a name different from that of his or her parents or from
that of other children of the same mother and father whose names are
registered in Western Australia if he is satisfied that the use of that
surname is in accordance with the recognised religious custom or naming
procedure of the ethnic group to which one or both of the parents of the child
belong.
(2) The Registrar General may require evidence to
support this application.
* Delete whichever is inapplicable.
Registration of Births, Deaths and Marriages Act 1961
Form No. 13
Section 73A
Regulation 16C
Western Australia
APPLICATION UNDER SECTION 73A FOR CHANGE OF SURNAME OF CHILD
Please read the Notes at the bottom of this page before completing this form.
We...........................................................................................
(Full names, addresses and occupations of mother and father)
parents
of....................................................................................
(Registered name of the child)
who was born on........................at........................in Western
Australia, apply to the change our child’s surname
from..........................................
(registered surname)
to . . . . . . . . . . . . . . . . . . . . . . and hereby declare
that —
(proposed surname)
1. The proposed surname is a name selected in
accordance with the religious custom or naming procedure
of...................................................
(name or description of ethnic group)
2. Both of us are members of that ethnic group.
* I..........................................am a member of that ethnic group.
3. We agree to this application.
Dated this.................................day
of................................, 19........
at.....................................................................
Signature of:
Father..................
Witness...........................
Address...........................
Mother..................
Witness...........................
Address...........................
Note:
(1) This form is to be completed where the surname
of a child has been entered in a register in Western Australia and the mother
and the father wish to substitute a different surname in the register.
(2) Application must be made no later than
6 months after the day set forth in column 3 of the Third Schedule
against the relevant ethnic group.
(3) The proposed surname must be in accordance
with a recognised religious custom or naming procedure of the ethnic group to
which one or both of the parents of the child belong as prescribed by the
regulations.
(4) The Registrar General may require evidence to
support this application.
* Delete whichever is inapplicable.
[ Second Schedule amended by Gazette
10 January 1966 p.58; 24 January 1986 pp.259-61.]