Mount Jerome Crematorium
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1 Mount Jerome Crematorium Form A Mount Jerome House, 158 Harold s Cross Road, Dublin D6W H98 Telephone: Fax: medref@mountjerome.ie FUERAL DIRECTOR S COFIRMATOR ORDER FORM PLEASE TICK WHETHER FORM C OR FORM D TO FOLLOW Funeral Director... Address... Telephone o.... ame of Deceased... Late Residence... Place of Death (if different from above... Age... Sex... Religion... Date of death... Married Single Separated Divorced Widow/er Civil Partner (Same Sex Cremation to take place: Day... Date... Time... UR CHOICE: Green Poly Urn Antique Metal Urn Wooden Casket Keepsake(s Supplied Urn B! ASHES OF DECEASED ARE ORMALL AVAILABLE FOR COLLECTIO 3/4 WORKIG DAS AFTER THE CREMATIO SERVICE DIGITAL PICTURES / VIDEOS Which of the below is to be Shown during the Service on the Large Chapel Digital Screen (situated just behind the coffin? Picture Slide Show Video Which of the below Digital Sources will be used for the above? Smartphone USB Stick Tablet Laptop B! The service length time will determine how many digital pictures / videos can be shown If the Deceased has any of the Below Implants, these must be removed as they will damage the Cremator whilst Cremating. (a Heart Pacemaker (b Heart Defribulator (c Radioactive Implant (d Artificial Arms or Legs (e Fixion Implant (f Baclofen Pump (g GT Skin Patch OTE: CREMATIO MA BE REFUSED IF A OF THE ABOVE IMPLATS ARE OT REMOVED o batteries, bottles, alcohol, electronic devices, shoes or glass permitted in the coffin as these will also damage the cremator whilst cremating. If the coffin is longer than 7 1 /2ft, wider than 3ft or more than 2ft in height (or made from cardboard please contact the crematorium to see if the coffin is suitable for cremating. Any coffins with pitch inside will be refused for cremation!! I hereby certify that I have complied with all regulations laid down by Mount Jerome Crematorium Signature of Funeral Director... FORMS TO BE SCAED AD ED TO MEDREF@MOUTJEROME.IE AS SOO AS POSSIBLE
2 This form is issued by Mount Jerome Crematorium, Harolds Cross, Dublin Tel: Form B APPLICATIO FOR CREMATIO B EXECUTOR OR EAREST EXT OF KI ALL QUESTIOS MUST BE ASWERED PURSUAT TO THE BE LAWS MADE B MOUT JEROME CREMATORIUM This application should be made preferably by an executor and witnessed by a third party at bottom of this page. If not, then by the nearest surviving relative (SR. This application CAOT be made by a Common Law partner or a friend. (ame of Applicant... Mr./Mrs./Miss ie ext of Kin or Executor (Address (Occupation or Description... apply to Mount Jerome Crematorium to undertake the cremation of the remains of:- (ame of Deceased... First ame in full (Address... (Occupation... Age... Sex... Religion... Date of death... Married Single Separated Divorced Widow/er Civil Partner (Same Sex at MOUT JEROME CREMATORIUM. on... The answers must be completed by the applicant (Executor or SR only!. 1. Are you an executor or the nearest surviving relative (SR of the deceased?, Please state which. If you are the SR, please state your relationship to the deceased If answer to 1 is o. ( a our relationship to the deceased. (a... (b The reasons why the application is made by you and not an executor or nearest surviving relative. (b Has the nearest surviving relative of the Deceased been informed of the proposed cremation? 4. Do you know or have any reason to suspect that the death of the deceased was due directly or indirectly to (a Violence or misadventure (b Unfair means (c egligence (d Malpractice on the part of others (e Poison / Alcohol / Drug related 5. Has the deceased been fitted with any artificial implant? Is es, Please state what form below and inform your funeral director as he / she has alist of implants that will damage the cremator on Form A of the Cremation Forms.... B! o batteries, bottles, alcohol, electronic devices, shoes or glass permitted in the coffin as these items will also damage the cremator whilst cremating. Any residual metals (i.e. coffin nails, body implants following cremation are recycled. Monies received from this recycling programme are donated annually to Our Lady s Hospice Harold s Cross. OTE: CREMATIO MA BE REFUSED IF A DAMAGIG IMPLAT IS OT REMOVED B! THE CREMATIO ASHES OF DECEASED MUST BE COLLECTED O LATER THA 1 MOTH AFTER THE CREMATIO SERVICE. I declare that to the best of my knowledge and belief the information given in this, is correct and no material in particular has been omitted. Date:... (Signature of Applicant i.e. Executor or SR... The applicant is known to me and Ihave no reason to doubt the truth of any of the information furnished by the applicant. Date:... (Signature of Witness... (Address... Please Print ame... Date... This form when completed should be sent to the Secretary, Mount Jerome Crematorium, 158 Harolds Cross Road, Dublin D6W H98 medref@mountjerome.ie
3 This form is issued by Mount Jerome Crematorium, 158 Harolds Cross Road, Dublin D6W H98 Tel: These Certificates are to be returned to the Funeral Director or Crematorium AS SOO AS POSSIBLE DEAR DOCTOR, PLEASE READ BELOW VER CAREFULL!!! Before you begin to answer this form, please note that you must fulfil all the criteria below first: (a Only a Doctor who attended the patient can complete this form. It is not permitted for two Doctors to co-complete or co-sign this form. (b ou must have at least some knowledge of the deceased s medical history. (c ou must have seen the deceased before death, within 4weeks of death. (d ou must have seen the deceased after death. (e ou must be fully registered on the Medical Register of Ireland i.e. Post-Intern year (f ou must report the death to your Coroner, if applicable. If you do not fulfil ALL of the above criteria, then STOP! ou cannot continue. Please contact the Funeral Director immediately Form C MEDICAL CERTIFICATE FORM C I am informed that application is about to be made for the cremation of the remains of: (ame of Deceased... (Address... (Occupation of Deceased... (Age... HAVIG SEE AD IDETIFIED THE BOD BEFORE AD AFTER DEATH I give the following answers to the questions set out below:- 1. (a Were you the regular attending doctor of the Deceased (a... (b If so, for how long? (b (a Did you attend the Deceased during his or her last illness (a... (b If so, for how long? (b (a When did you last see the Deceased alive? (Date... ( say how many days or hours before death (Days or Hours (a How soon after death did you see the body? and (a... (b What examination did you make? (b... If you did not see the body after death - you cannot complete this form 5. (a On what date and at what hour did he or she die? Date... Hour (a What was the place where the Deceased died? (a... Give address and (b Say whether Deceased s own residence, lodging, hotel hospital, nursing home etc. (b (a Are you a relative of the Deceased? (a... ( b If yes, state relationship (b Have you, so far as you are aware, any financial interest i n the death of the Deceased.
4 Form C. (COTIUED 9. Cause of death and duration of last illness: I. O ABBREVIATIOS I. Approximate interval between onset and death Disease or condition (a... directly leading to death due to (or as a consequence of Antecedent causes (b... Morbid conditions, if any, due to (or as a consequence of giving rise to the above cause, stating the underlying condition last (c... II. II. Other significant conditions contributing to the death but... not related to the disease or condition causing it. OTE: IF DEATH IS DUE TO UATURAL CAUSES, (IE FALL, FRACTURE, ALCOHOL / DRUG RELATED OU MUST REPORT THE DEATH TO OUR COROER 10. (a State how far the answer to the last question is the result of your own observation.... (b If not your own observation, what was the source of your information? (a Have you or any other doctor performed an Autopsy on the body? (a... (b If es state by whom the examination was made. (b By whom was the Deceased nursed during his or her last illness. (Give names and say whether professional nurse, relative etc. If the illness was a long one this question should be answered with reference to p eriod of four weeks before the death. 13. Who were the persons present (if any at the moment of death. 14. In view of your 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 stated in 9. above?
5 15. Have you any reason to suspect that the Deceased person died either directly or indirectly as a result of: ( a Violence or misadventure (a es / o (b Unfair means (b Form C. (COTIUED es / o... ( c egligence or misconduct (c es / o ( d Malpractice on the part of others (d es / o ( e Poison / Alcohol / Drug related (e es / o (including conditions related to chronic alcohol abuse ( f Falls / Fractures (f es / o ( g Any other than natural illness (g es / o or disease for which he/she had been seen and treated by a registered medical practitioner within one month before his/her death: IF OU ARE I A DOUBT ABOUT A OF THE ABOVE ASWERS, PLEASE DISCUSS WITH OUR COROER. 16. Do you know or have you any reason to suspect that the death occurred under or within 24 hours of an anaesthetic or Medical Procedure (a Have you any reason to suspect that the death of the Deceased should properly be reported to the Coroner? (a... (b If so have you or anybody else done so (b... What was the outcome of the discussion Have you any reason whatever to suppose a further e xamination of the body to be desirable? 19. (a Did you sign the medical Certificate of the Cause of Death? (a... (b If not who has? (b (1 Has the Deceased been fitted with? (a A Cardiac Pacemaker / Defribulator (1. (aes / o... ( b A Radioactive Implant (bes / o.... ( c A Fixion Implant (ces / o.... (d A Bacloflen Pump (e Other Prosthesis (ees / o... (2 If the answer to any of the above is in the a ffirmative, has this implant been removed? (2. es / o... OTE: CREMATIO MA BE REFUSED IF A ARTIFICIAL IMPLAT IS OT REMOVED AS THE WILL DAMAGE THE CREMATOR (des / o... OUR COMPLETIO OF THIS FORM C WILL BE DEEMED VOID IF OU ARE OT FULL REGISTERED O THE MEDICAL REGISTER OF IRELAD I.E. POST ITER EAR I hereby certify that the answers given above are true and accurate to the best of my knowledge and belief. ame... (Signature... (please insert name here in block capitals. Date:... Telephone o... (Address Registered Qualification... ear & Month of Full Registration on The Medical Register of Ireland... (not provisional Medical Registration o...
6 Mount Jerome Crematorium COROER S CERTIFICATE FOR CREMATIO I Certify that:- I am satisfied that there are no circumstances likely to call for further examination of the body. Form D PARTICULARS OF DECEASED PERSO Full ames... Sex... Age... Date of Death... Place of Death... (Please insert name here in block capitals... Signature... Coroner for the of Date... If the deceased has any of the below implants, these must be removed as they will damage the Cremator whilst Cremating. (a Heart Pacemaker (b Heart Defribulator (c Radioactive Implant (dartificial Arms or Legs (e Fixion Implant (f Baclofen Pump (g GT Skin Patch OTE: CREMATIO MA BE REFUSED IF A ARTIFICIAL IMPLAT LISTED ABOVE IS OT REMOVED. OTE: This Certificate is issued for the purpose of cremation only and must be delivered to the Funeral Director or Mount Jerome Crematorium as soon as possible. The Cremation cannot be proceeded with unless this Certificate is so delivered. Mount Jerome Crematorium Contact Details: Telephone: medref@mountjerome.ie
Mount Jerome Crematorium Ltd. Mount Jerome House, Harold s Cross, Dublin 6W. Telephone: Fax:
Mount Jerome Crematorium Ltd. Mount Jerome House, Harold s Cross, Dublin 6W. Telephone: 4977956 Fax: 4960994 Email: medref@mountjerome.ie Form A FUERAL DIRECTOR S COFIRMATOR ORDER FORM PLEASE TICK WHETHER
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