Form BF4
Application for burial of the remains of a pregnancy loss by health authority or body (shared or individual)
| Burial authority logo and/or address: | ||
|---|---|---|
| Burial number [official use only] | ||
| Burial authority registration number: | ||
| Burial ground | ||
| Full name of deceased | ||
| Day and date of burial | ||
| Time of service |
This is a statutory form made under regulation 3 of the Burial (Applications and Register (Scotland) Regulations 2024 and the information and questions contained in it should not be changed.
This form is used to apply for the individual or shared burial of the remains of a pregnancy loss in Scotland, where the loss occurred on or before the end of the 24th week of gestation and showed no signs of life and the loss was for any reason (i.e. termination or miscarriage).
This application must be completed and signed by the person authorised to make the application for burial. Each pregnancy loss must be identified by the hospital or clinic ID number.
The application is made to the burial authority you want to carry out the burial. The burial authority is the organisation responsible for managing the burial ground where the burial is to take place. The burial authority will need to check the form to make sure it contains all of the necessary information. Missing or inaccurate information may result in the burial being delayed or refused. If you are unsure about what information is required, or what any part of the form means, you can speak to the funeral director who is making the arrangements, staff at the burial authority or to any other person who is arranging the burial.
Personal data
The information provided on this form is a legal requirement under the Burial and Cremation (Scotland) Act 2016 (“the Act”) and will be processed in line with data protection legislation. The data will be held by the burial authority. It will be held securely, in confidence and processed solely for the purposes set out by or under the Burial and Cremation (Scotland) Act 2016. It will not be shared with any third party other than an inspector of burial, if requested. You have the right to know what data is held about you and you can, by contacting the burial authority in writing, receive a copy of that data. The burial authority is obliged to include in their privacy notice how the information will be held, for how long and how you may make a complaint to the Information Commissioner’s Office.
Burial Authority Address 2: Council Offices School Place Kirkwall, KW15 1NY registrar@ orkney.gov.uk
IMAGE: Page 1 contains Form BF4, an application form with fields for burial details, burial authority information and the deceased’s details, followed by statutory guidance and personal-data information. The Burial Authority Address 2 field contains: “Council Offices School Place Kirkwall, KW15 1NY registrar@ orkney.gov.uk”.
Section 1: Application for the burial of the remains of a pregnancy loss(es)
This section is used to record the details of the pregnancy loss(es) (please tick only one option below and move to relevant section(s)).
The person applying for the burial is ‘the applicant’ and has the legal right to apply for the burial under section 78 of the Burial and Cremation (Scotland) Act 2016.
[ ] This application is for the burial of an individual pregnancy loss (please complete section 1A).
[ ] This application is for the shared burial of pregnancy losses (please complete section 1B).
Section 1A: Individual burial of pregnancy loss
If a pregnancy loss is to be buried individually, no other pregnancy loss(es) are to be included on this form.
I, .................................................................................................. (print name of applicant) on behalf of
I, ................................................................................................... (organisation) as the authorised and designated person, declare that I hold paperwork relating to the pregnancy loss listed below, signed by the medical practitioner/registered nurse/registered midwife, and that the paperwork includes a declaration that the pregnancy ended before or on completion of its 24th week and that the pregnancy loss showed no signs of life.
| Container Number | Pregnancy Loss Unique Identifier | |
|---|---|---|
| 1 |
Section 1B: Shared burial of pregnancy loss
I, ...................................................................................................................... (print name) on behalf of
I, ................................................................................................... (organisation) as the authorised and designated person, declare that I hold paperwork relating to each of the pregnancy losses listed below, signed by the medical practitioner/registered nurse/registered midwife, and that the paperwork includes a declaration that each pregnancy ended before or on completion of its 24th week and that each pregnancy loss showed no signs of life.
IMAGE: Page 2 contains Section 1 of the form, with checkboxes for individual or shared burial, declaration fields for the authorised applicant and organisation, and a one-entry table for an individual pregnancy loss.
Container number: ....................................................................
| Container number | Pregnancy Loss Unique Identifier | Container number | Pregnancy Loss Unique Identifier | Container number | Pregnancy Loss Unique Identifier | Container number | Pregnancy Loss Unique Identifier |
|---|---|---|---|---|---|---|---|
| 1 | 14 | 27 | 40 | ||||
| 2 | 15 | 28 | 41 | ||||
| 3 | 16 | 29 | 42 | ||||
| 4 | 17 | 30 | 43 | ||||
| 5 | 18 | 31 | 44 | ||||
| 6 | 19 | 32 | 45 | ||||
| 7 | 20 | 33 | 46 | ||||
| 8 | 21 | 34 | 47 | ||||
| 9 | 22 | 35 | 48 | ||||
| 10 | 23 | 36 | 49 | ||||
| 11 | 24 | 37 | 50 | ||||
| 12 | 25 | 38 | |||||
| 13 | 26 | 39 |
IMAGE: Page 3 contains the shared-burial table, allowing Pregnancy Loss Unique Identifiers to be entered for container numbers 1 through 50. The entries are arranged in four groups: 1–13, 14–26, 27–39 and 40–50.
Section 2: Burial details
| Field | Details |
|---|---|
| Name of burial ground | |
| Burial ground address and postcode | |
| Type of lair(a) | [ ] New lair [ ] Existing lair, but no previous burial Please describe location in burial ground (e.g. section and lair number) ................................................................................................................ [ ] Existing lair which contains a previous burial Please describe location in burial ground (e.g. section and lair number) and give details of last burial (deceased name and date of burial) ................................................................................................................ |
| Any other requests or instructions? |
(a) A lair is a Scottish term for a burial plot or grave.
Section 3: Applicant’s declaration and consent
Declaration of entitlement to apply for burial
I declare that the details and information provided in this form are complete and correct to the best of my knowledge and that authorisation for the disposal has been obtained, in accordance with Part 3 of the Burial and Cremation (Scotland) Act 2016.
Signed: ..............................................................................................................................................
Full Name: ..............................................................................................................................................
Date: ..............................................................................................................................................
Organisation: .......................................................................................................................................
Address and postcode: ...........................................................................................................................
Phone number: .......................................................................................................................................
IMAGE: Page 4 contains Sections 2 and 3, with fields for burial-ground details, lair type and location, additional requests, and the applicant’s declaration, signature and contact details.