Certification of Death (Scotland) Act 2011 Statutory Guidance

Annex A

Application under section 4 of the Certification of Death (Scotland) 2011 Act

Please note that all sections of this form must be completed. The medical certificate of cause of death must be included with this application.

Section A – Applicant details

Full Name (include title):

Address:

Please provide at least one method of contact:

• Telephone Number:
• Email Address:

Reason why applicant classifies as an “interested person”^[22] (please tick). Applicant is:

a person who, under the Registration of Births, Deaths and Marriages (Scotland) Act 1965, is required or stated to be qualified to give information concerning the deceased’s death

a health care professional (or other carer) who was involved with the deceased’s care prior to the deceased’s death

the funeral director responsible for the funeral arrangements of the deceased^[23]

the person having charge of the place of disposal of the body of the deceased²

Section B – Deceased person’s details

Has the funeral taken place?

Yes, where did it take place …………………………..

Was it a burial or cremation …………………………..

No, when is it planned for? ……………………………………….

Name (as it appears on the Death Certificate):

Date of Death:

Has the death been registered? Yes

No

Registration District Number:

Registration Entry Number:

Section C – Relevant information

Please provide any additional relevant information regarding this application

Section D – Declaration

The applicant hereby certifies that to the best of their knowledge and belief the information contained in this application is complete, and correct, and, that the date of death occurred

• on or after 13 May 2015 and
• within the last 3 years.

Signature of applicant (manual or electronic):

Date:

Note: Please enclose/attach a copy of the MCCD (Medical Certificate of Cause of Death) with this application. This can be obtained from the certifying doctor.