New Zealand Gazette – 1928 – No. 81

Page 3098

✨ Cremation Certificates



  1. What was the cause of death?
    $\left{ \begin{array}{c} \text { Primary. } \ \text { Secondary. } \end{array}\right.$
    $[\text { Specify the disease, injury, } \& c . \text {, and, if possible, distinguish }]$
    what primary from the secondary
    cause as in the death certificate.]
    What was its duration in years,
    months, or days ?
  2. What was the mode of death [Say
    whether syncope, coma, exhaustion, convul-
    sions, $\&$ c.]
    What was its duration in days,
    hours, or minutes ?
  3. State how far the answers to the
    last two questions are the result of your
    own observations, or are based on state-
    ments made by others. If on statements
    made by others, say by whom.
  4. 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?
  5. By whom was the deceased nursed
    during his [or her] last illness? [Give
    names, and say whether professional nurse,
    relative, &c. If the illness was a long one,
    this question should be answered with refer-
    ence to the period of four weeks before death.]
  6. Was the deceased attended during
    his [or her] last illness by any medical
    attendant besides yourself?
  7. Who were the persons (if any) pre-
    sent at the moment of death?
  8. 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?
  9. 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.
  10. Have you any reason whatever to
    suppose a further examination of the body
    to be desirable?
  11. Have you given the certificate re-
    quired for the registration of 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 $\left{\begin{array}{l} \text { disease } \ \text { accident } \end{array}\right.$ or which makes it desirable that the body
    should not be cremated.
    [Signature.]
    [Address.]
    [Registered qualifications.]
    [Date.]
    NOTE.-This certificate must be handed or sent in a closed envelope by the
    medical practitioner who signs it to the Medical Referee.
    FORM C.
    THE CREMATION REGULATIONS, 1928.
    Certificate after Post-mortem Examination.
    I HEREBY certify that, acting on the instructions of*, Medical Referee
    under the Cremation Regulations, 1928, I made a post-mortem examination of
    the remains of—
    $\begin{aligned}&\text {[Name.] } \&\text {[Address.] } \&\text {[Occupation.] }\end{aligned}$
    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 holding an inquest.
    [Signature.]
    [Address.]
    [Date.]
    [Registered qualifications.]
  • Where the Medical Referee himself gives the certificate strike out the words “on the
    instructions of” and insert “as.”
  • The words in italics 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.


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✨ LLM interpretation of page content

🏥 Certificate of Medical Attendant for Cremation (continued from previous page)

🏥 Health & Social Welfare
Cremation, Medical Certificate, Death, Medical Attendant

🏥 Certificate after Post-mortem Examination

🏥 Health & Social Welfare
Cremation, Post-mortem Examination, Medical Certificate, Death