Schedule 1

Forms

In force

Form 1

[Reg. 4]

Coroners Act 1996

(Section 9)

OATH FOR STATE CORONER

I ................................................... (person’s name) ............................................... do solemnly, sincerely and truly swear that I will well and truly serve the State, according to law, in the office of State Coroner, and I will do right to all manner of people after the laws and usages of this State, without fear or favour, affection or ill will.

So help me God!

[Form 1 amended: Gazette 19 Apr 2005 p. 1295.]

Form 2

[Reg. 4]

Coroners Act 1996

(Section 9)

AFFIRMATION FOR STATE CORONER

I .................................................. (person’s name) ............................................... do solemnly, sincerely and truly declare and affirm that I will well and truly serve the State, according to law, in the office of State Coroner, and I will do right to all manner of people after the laws and usages of this State, without fear or favour, affection or ill will.

[Form 2 amended: Gazette 19 Apr 2005 p. 1295.]

Form 3

[Reg. 6]

Coroners Act 1996

(Section 26(1))

RECORD OF INVESTIGATION INTO DEATH

Ref. No.

I, ............................................................................, Coroner, having investigated:

1. The death of .................................................................................................

2. *Without holding an inquest.

*With an inquest held at ..............................................................................

on .................................................................................................... 20........

3. *Find that —

*The identity of the deceased person was and that death occurred on / / at from (state cause of death)

*in the following circumstances

4. *Decide not to continue to investigate the death having determined under section 19A(1) of the Coroners Act 1996 that the death was due to natural causes and was a reportable death solely because it appears to have been unexpected.

5. *Make no finding as to how the death occurred having determined under section 25(1A)(b) of the Coroners Act 1996 that there is no public interest to be served in making such a finding.

Comments:

Coroner.

* Delete those not required.

[Form 3 amended: Gazette 1 Feb 2019 p. 225‑6.]

Form 4

[Reg. 7]

Coroners Act 1996

(Section 29(1))

CERTIFICATE PERMITTING BURIAL, CREMATION OR OTHER DISPOSAL

I, ............................................................................................., Coroner, PERMIT

*Burial.

*Cremation.

*Other disposal, namely ......................................................................................... of the body of .........................................................................................................

Dated at .......................... the .......................... day of .............................. 20........

Coroner.

* Delete those not required.

Form 5

[Reg. 10]

Coroners Act 1996

(Section 38(1))

ORDER FOR EXHUMATION OF BODY

Ref. No.

To:

Postcode:

Information about the deceased person

Name
of

Information about the death

When
Where

Time Day Month Year

Information about the burial of the body

When
Where

Day Month Year

Postcode

Information about the making of this order

The body must be exhumed and taken to ................. and held until I order that it may be buried again.

Information about the order

Made by
When
Signature

State Coroner

Day Month Year

Form 6

[Reg. 12]

Coroners Act 1996

(Section 32(4))

NOTICE RESTRICTING ACCESS TO AREA

RESTRICTED AREA

NO ENTRY WITHOUT CORONER’S AUTHORITY

PENALTY: $2 000 FINE

Form 7

[Reg. 13]

Coroners Act 1996

(Section 32(2))

RESTRICTION OF ACCESS

Investigation into the death of ................................................................................

Description of area to which access has been restricted by Coroner’s investigator —

.................................................................................................................................

Reasons for seeking restriction of access —

.................................................................................................................................

Is access being restricted at the present time: Yes No

If Yes, specify the time and date when the restriction first imposed .....................

Period for which restriction is sought ....................................................................

Restriction agreed with

Restriction not agreed with

....................................

Signature of Coroner

Date: / / .

Form 8

[Reg. 14(1)]

Coroners Act 1996

(Section 33(3))

AUTHORISATION OF CORONER’S INVESTIGATOR

I, ..........................................................................., Coroner, reasonably believing it necessary for investigating —

the death of .............................................................................................................

AUTHORISE ....................................................................................., a coroner’s investigator —

* to enter (specify place) ................................................................................

* to inspect (specify place) ............................................................................. and anything in it.

* to take a copy of (specify documents or classes of documents) ...................

* to take possession of (specify things or classes of things) at or between the hours of .............................. and .............................. during the period commencing the ............. day of ...................... 20........ and concluding on the ............. day of ........................ 20........ (such period not to exceed one month after the date of this authority).

Dated at .................... the ......................... day of ..................................... 20........

Coroner.

* Delete those not applicable.

Form 9

[Reg. 14(3)]

Coroners Act 1996

(Section 33(5))

UNDERTAKING TO COMPLY WITH CONDITIONS OF RELEASE

I, ...................................., Coroner, having taken possession of the certain things, or classes of things, pursuant to section 33 of the Coroners Act 1996 for the purpose of an investigation into the death of .........................................................

Authorise the release of: .................... (description of thing/s) .............................

To ............. (name of person to whom thing/s are to be released) ........................

Of ............. (address of that person) ......................................................................

On condition that ............. (any conditions) ..........................................................

I, ............. (name of person to whom thing/s are to be released) ........................... enter this undertaking and acknowledge receipt of a copy thereof setting out my obligations concerning the conditions of release of the thing/s specified in this undertaking and I acknowledge that if I fail to comply with these conditions that I am liable to a penalty.

Signature of person entering undertaking.

I am satisfied that, before releasing the thing/s specified in this undertaking, ............. (name of person to whom thing/s are to be released) ........... understood the nature and extent of his/her obligations under the conditions of this undertaking and the consequences of his/her failure to comply with them.

Undertaking entered on / / at in the State of Western Australia before me

Coroner.

Form 10

[Reg. 16(1)]

Coroners Act 1996

(Section 46(1))

SUMMONS TO GIVE EVIDENCE OR BRING DOCUMENTS

To:

Postcode:

An inquest is to be held into—

The death of
Which happened on

Day Month Year

What you must do

You must go to the inquest and

Give evidence
Bring the following documents and materials

Information about the inquest

Where you must go
To be held at

When

The Coroner’s Court of Western Australia

Time Day Month Year

Information about this summons

Issued at
By

Signature

Date / /
State Coroner
Coroner
Coroner’s Registrar

If further information is required, telephone: ..................

[Form 10 amended: Gazette 11 Mar 2008 p. 816.]

Form 11

[Reg. 16(3)]

Coroners Act 1996

(Section 46(4))

WARRANT OF APPREHENSION WHERE WITNESS FAILS TO APPEAR

In the Coroner’s Court of Western Australia

at .............................................................................................................................

INQUEST INTO THE DEATH OF: .....................................................................

To all members of the Police Force of the State of Western Australia.

The witness who has failed to appear is .................................................................

of ............................................................................................................................

THE WITNESS has neglected to appear at the time and place appointed in and by a Summons to attend as witness or to produce documents or other materials and it is proved to me, the undersigned Coroner, upon oath, that the said Summons was served on the witness.

I AUTHORISE you to enter and search at any time with all force as may be necessary any dwelling‑house, building, premises, ship, aircraft or any place where the witness is suspected to be present AND I ORDER that you apprehend the witness and bring the witness before the said Coroner’s Court to answer the said Summons and to be further dealt with according to law.

Dated at .......................... the ................... day of ................................ 20.............

Coroner.

[Form 11 amended: Gazette 12 Feb 2013 p. 922.]

Form 12

[Reg. 18(1)]

Coroners Act 1996

(Section 45(1))

ORDER EXCLUDING PEOPLE FROM AN INQUEST

This inquest is being held into—

The death of
Which happened on

Day Month Year

Information about this order

Who does it apply to?

How long does it apply?

The Coroner has ordered that the following people:

must not enter the room where the inquest is being held.

This order applies—

From Time Day Month Year

To Time Day Month Year

For the whole of the inquest.

What if I have been summoned?

You must wait outside the room until you are called in to give evidence or deliver documents or other materials.

Information about the making of this order

Made by

Where
When
Signature

State Coroner

Coroner

Time Day Month Year

Form 13

[Reg. 20]

Coroners Act 1996

OATH FOR WITNESS

Do you solemnly, sincerely and truly swear that the evidence that you give at this inquest touching the death (or suspected death) of ......................................... shall be the truth, the whole truth, and nothing but the truth?

So help you God!

Form 14

[Reg. 20]

Coroners Act 1996

AFFIRMATION FOR WITNESS

Do you solemnly, sincerely and truly declare and affirm that the evidence that you give at this inquest touching the death (or suspected death) of ...................... shall be the truth, the whole truth and nothing but the truth?

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