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Mount Jerome House, 158 Harold’s Cross Road, Dublin 6W.
FUNERAL DIRECTOR’S CONFIRMATORY ORDER FORM
Place of Death (if different from above) .
Age . Sex . Religion . Date of death.
Mode of disposal of cremated remains:
For burial in grave in Mount Jerome Cemetery NB! ASHES OF DECEASED ARE NORMALLY AVAILABLE FOR COLLECTION 3/4 WORKING DAYS AFTER THE CREMATION SERVICE 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 (e) Fixion Implant (f) Baclofen pump NOTE: CREMATION MAY BE REFUSED IF ANY OF THE ABOVE IMPLANTS ARE NOT REMOVED
No batteries, bottles, alcohol, electronic devices or glass permitted in the coffin as these will also damage the cremator whilst cremating.
wider than 3ft or more than 2ft in height, please contact the crematorium to see if coffin is suitable for cremating.
No cardboard coffins are accepted for cremation or coffins with pitch inside.
I hereby certify that I have complied with all regulations laid down by Mount Jerome Crematorium Limited FORMS TO BE SCANNED AND EMAILED TO [email protected] AS SOON AS POSSIBLE APPLICATION FOR CREMATION BY EXECUTOR OR NEAREST NEXT OF KIN
PURSUANT TO THE BYE LAWS MADE BY MOUNT JEROME CREMATORIUM LIMITED 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 survivingrelative (NSR). This application CANNOT be made by a Common Law partner or a friend. (Name of Applicant). Mr./Mrs./Missie Next of Kin or Executor apply to Mount Jerome Crematorium Company to undertake the cremation of the remains of:- The answers must be completed by the applicant (Executor or NSR only!).
Are you an executor or the nearest surviving relative (NSR) of the deceased?, Please state which. If you are the NSR, please state your (b) The reasons why the application is made by you and not an executor or nearest surviving relative.
Has the nearest surviving relative of the Deceased been informed of the proposed cremation? Do you know or have any reason to suspect that the death of the deceased was due directly or indirectly to Has the deceased been fitted with any artificial implant? Is Yes, 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 NB! No batteries, bottles, alcohol, electronic devices 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.
NOTE: CREMATION MAY BE REFUSED IF ANY DAMAGING IMPLANT IS NOT REMOVED
NB! THE CREMATION ASHES OF DECEASED MUST BE COLLECTED NO LATER THAN 1 MONTH AFTER THE CREMATION 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.
(Signature of Applicant) i.e. Executor or NSR .
The applicant is known to me and I have no reason to doubt the truth of any of the information furnished by the applicant.
Fax: 01-496 0994 Email: [email protected] These Certificates are to be returned to the Funeral Director or Crematorium AS SOON AS POSSIBLE
DEAR DOCTOR, PLEASE READ BELOW VERY CAREFULLY !!!
Before you begin to answer this form, please note that you must fulfil all the criteria below first:
(a) You must have at least some knowledge of the deceased’s medical history.
(b) You must have seen the deceased before death, within 4 weeks of death.
(c) You must have seen the deceased after death.
(d) You must be fully registered on the Medical Register of Ireland i.e. Post-Intern year
(e) You must report the death to your Coroner, if applicable.
If you do not fulfil ALL of the above criteria, then STOP!
You cannot continue. Please contact the Funeral Director immediately
I am informed that application is about to be made for the cremation of the remains of: HAVING SEEN AND IDENTIFIED THE BODY BEFORE AND AFTER DEATH
I give the following answers to the questions set out below:- (a) Were you the regular attending doctor of the Deceased (a) Did you attend the Deceased during his or her last illness (a) How soon after death did you see the body? and (a) On what date and at what hour did he or she die? (a) What was the place where the Deceased died? (b) Say whether Deceased’s own residence, lodging, hotel Have you, so far as you are aware, any financial interest NO ABBREVIATIONS
NOTE: IF DEATH IS NOT DUE TO NATURAL CAUSES, (IE FALL, FRACTURE, ALCOHOL / DRUG RELATED) YOU MUST REPORT THE DEATH TO YOUR CORONER (a) State how far the answer to the last question (b) If not your own observation, what was the (a) Have you or any other doctor performed an (b) If “Yes” state by whom the examination was made.
By whom was the Deceased nursed during his or her (Give names and say whether professional nurse, relative etc. If the illness was a long one this question should be answered with reference to Who were the persons present (if any) at the moment 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 Have you any reason to suspect that the Deceased person died either directly or indirectly as a or disease for which he/she had been seen and treated by a registered medical practitioner within one month before his/her death: IF YOU ARE IN ANY DOUBT ABOUT ANY OF THE ABOVE ANSWERS , PLEASE DISCUSS WITH YOUR CORONER.
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? ( ) If so have you or anybody else done so What was the outcome of the discussion .
Have you any reason whatever to suppose a further (a) Did you sign the medical Certificate of the Cause of Death? (2) If the answer to any of the above is in the NOTE: CREMATION MAY BE REFUSED IF ANY ARTIFICIAL IMPLANT IS NOT REMOVED AS THEY WILL DAMAGE THE CREMATOR
YOUR COMPLETION OF THIS FORM C WILL BE DEEMED VOID IF YOU ARE NOT FULLY REGISTERED ON THE MEDICAL REGISTER OF IRELAND
I.E. POST INTERN YEAR
I hereby certify that the answers given above are true and accurate to the best of my knowledge and belief.
(please insert name here in block capitals).
Year & Month of Full Registration on The Medical Register of Ireland .
CORONER’S CERTIFICATE FOR CREMATION
I am satisfied that there are no circumstances likely to call for further examination of the body.
PARTICULARS OF DECEASED PERSON
(Please insert name here in block capitals).
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 (e) Fixion Implant (f) Baclofen pump NOTE: CREMATION MAY BE REFUSED IF ANY ARTIFICIAL IMPLANT LISTED ABOVE IS NOT REMOVED.
NOTE: 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 Contact Details:
Telephone: 01-497 7956 Fax: 01-496 0994 Email:[email protected]
DEMENTIA SCALE FOR DOWN SYNDROME ( DSDS ) This scale is an informant-based instrument for assessing the presence or absence of dementia in adults with Down syndrome and DD adults without Down syndrome. It was developed in British Columbia and standardized on 70 adults with DS mostly in the severe or profound range who were followed up to 8 years. The longitudinal sample also had 37 a