Mount Jerome Crematorium Ltd. Mount Jerome House, Harold s Cross, Dublin 6W. Telephone: Fax:
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1 Mount Jerome Crematorium Ltd. Mount Jerome House, Harold s Cross, Dublin 6W. Telephone: Fax: medref@mountjerome.ie Form A FUERAL DIRECTOR S COFIRMATOR ORDER FORM PLEASE TICK WHETHER A 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... Occupation... Married Single Separated Divorced Widow/er Cremation to take place: Day... Date... Time... Mode of disposal of cremated remains: (a Private Disposal: Urn Casket Supplied Urn For burial in grave in Mount Jerome Cemetery B! ASHES OF DECEASED ARE ORMALL AVAILABLE FOR COLLECTIO 3/4 WORKIG DAS AFTER THE CREMATIO SERVICE (b Memorial Option: State which option:... How many spaces (max 3:... Confirm inscription:... 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 Radio active implant (d Artificial arms or legs OTE: CREMATIO MA BE REFUSED IF A OF THE ABOVE IMPLATS ARE OT REMOVED o batteries, bottles, alcohol, electronic devices or glass permitted in the coffin as these will also damage the cremator whilst cremating. If the coffin is longer than 7ft, wider than 2 o highly varnished / lacquered coffins are accepted for cremation. 1 /2 ft or more than 2ft in height, please contact the crematorium to see if coffin is suitable for cremating. ame and Address of person signing form B I hereby certify that I have complied with all regulations laid down by Mount Jerome Crematorium Limited Signature of Funeral Director...
2 This form is issued by Mount Jerome Crematorium Ltd., Harolds Cross, Dublin 6W. Tel: Fax: (ame of Applicant... Mr./Mrs./Miss ie ext of Kin or Executor (Address... (Occupation or Description... apply to Mount Jerome Crematorium Company to undertake the cremation of the remains of:- (ame of Deceased... First ame in full (Address... (Occupation... Age... Sex... Religion... Married Single Separated at MOUT JEROME CREMATORIUM. on... The answers must be completed by the applicant. 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 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 LIMITED This application should be made by an executor wherever practicable, and witnessed by a third party at bottom of this page. Divorced Widow/er 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 a list of implants that will damage the cremator on Form A of the Cremation Forms.... B! o batteries, bottles, alcohol, electronic devices or glass permitted in the coffin as these will also damage the cremator whilst cremating the Deceased. 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. (USUALL FROM OUR FUERAL DIRECTOR 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 I have 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 Limited, Harolds Cross Road, Mount Jerome, Dublin 6W.
3 This form is issued by Mount Jerome Crematorium Ltd., Harolds Cross, Dublin 6W. Tel: Fax: Form C 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 ou must have at least some knowledge of the deceased s medical history. (b ou must have seen the deceased before death, within 4 weeks of death. (c ou must have seen the deceased after death. (d ou must be fully registered on the Medical Register of Ireland for at least 2 years. (e 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 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 (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 OT DUE TO ATURAL 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 Who were the persons present (if any at the moment of death 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 or indirectly as a result of: ( a Violence or misadventure (a es / o (b Unfair means (b 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 ( 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; Form C. (COTIUED 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 Have you any reason whatever to suppose a further e xamination of the body to be desirable? (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 radio-active or other implant (bes / o.... (c Other Prosthesis (ces / o... (2 If the answer to (a, (b or (c above is in the a ffirmative, has this been removed? (2. es / o... OTE: CREMATIO MA BE REFUSED IS A ARTIFICIAL IMPLAT IS OT REMOVED AS THE WILL DAMAGE THE CREMATOR OUR COMPLETIO OF THIS FORM C WILL BE DEEMED VOID IF OU ARE OT REGISTERED FULL FOR 2 EARS (EXCLUDIG 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
6 Form D I Certify that:- COROER S CERTIFICATE FOR CREMATIO I am satisfied that there are no circumstances likely to call for further examination of the body. 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... (1. Has the Deceased been fitted with any artificial implants If es, please state what form, as several of these can damage the cremator... OTE: CREMATIO MA BE REFUSED IF A ARTIFICIAL IMPLAT 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. Telephone: Fax: medref@mountjerome.ie
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