Medical certificate - UK

Cremation 4
Medical certificate
replacing Form B
This form can only be completed by a registered medical practitioner.
Please complete this form in full, if a part does not apply enter ‘N/A’.
Part 1 Details of the deceased
Full name
Address
Occupation or last occupation if retired or not in work at the date of death
Where a past occupation of the deceased person may suggest that the death was due to industrial
disease, you should consider whether to refer the death to a coroner.
Part 2 The report on the deceased
1. What was the date and time of death of the deceased?
Date
Time
/ /
2. Please give the address where the deceased died.
Address
Please state whether it was the residence of the deceased or a hotel, hospital, or nursing
home etc.
Their home Hospital Other (please specify)
Hotel Nursing home
continued over the page
Regulation 16(c)(i) of the Cremation (England and Wales) Regulations 2008
01.09
Page 1/7
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