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BLACK TULIP FUNERALS PTY LTD
Trading as Black Tulip Funerals
7 Burrows Road, St Peters NSW 2044
Name of Deceased:
Date of Birth: Date of Death: Age: Gender: (circle) M F
It is standard practice for the body of a deceased person to be prepared for viewing, burial or cremation. This preparation is undertaken by funeral staff engaged by the funeral director and may also be carried out in the presence of, and with the assistance of, trainees. Photographs may need to be taken of the body to assist in this process, and in particular when the body must be transported to another funeral director or repatriated overseas. Any photographs will be kept secure and will only be used to assist in the identification, preparation and/or transfer of the deceased and/or reference to the Coroners Department and Forensic Science.
Please note that in the Occupational Health and Safety interests of employees of the funeral director, cemetery or crematorium, any implants or radioactive injectable solutions within the deceased's body may need to be removed prior to burial or cremation.
Are you aware of the presence of any of the following in the body of the above-named deceased?
(Please tick appropriate answer)
☐ Cardiac Pacemaker
☐ Cardiovascular Defibrillator
☐ Drug Infusion (Pain Relief/Control) Pump or Similar Device
☐ Radioactive Injectable Solutions
PLEASE NOTE: Where cremation has been selected, the prior use of radioactive injectable solutions may in some cases involve a delay in the final processing and collection of the cremated remains.
YES NO (Please circle appropriate answer)
If the answer is YES:
I confirm that I have advised appropriate members of the deceased's family and have authority to authorise Black Tulip Funerals Pty Ltd to undertake the following:
☐ Normal hygienic preparation that may include embalming**
☐ Photographing if required
☐ Removal of the above mentioned implants if required
Of the late:
Name of person giving authorisation:
Address:
Telephone number: Signed:
Date: / /
Relationship to the deceased:
Witnessed by Funeral Director/Consultant:
Name (printed):
Date: / /
** Embalming is the process of chemically treating a deceased human body to reduce the presence and growth of microorganisms, to retard organic decomposition, and to restore an acceptable physical appearance. **
Black Tulip Funerals Pty Ltd | 7 Burrows Road, St Peters NSW 2044 | www.blacktulipfunerals.com.au
