Office of the Chief Coroner
The Vital Statistics Act – Province of Ontario
I issue this warrant to bury the body of: (First Name(s), Last Name)
who died or was still-born at [Location – Name of facility (hospital, nursing home, residence) or address (if other location) and city, town, village or township]
on the (day)
day of (Month)
Coroner Name (Please print)
day of (Month)
I am an Appointee under section 16.1 of the Coroners Act, and the coroner who signed this form was not present in the location
where the death investigation of the deceased is being conducted or where the still-born was examined. I deliver this Warrant to
Bury on behalf of the coroner.
Appointee Name (Please print)
Appointee Signature (Must be original signature)
Note: This is not a burial permit under The Vital Statistics Act. A burial permit is also required.
Personal information contained on this form is collected under the authority of the Vital Statistics Act, R.S.O. 1990, c.V.4,
as amended, and may be used to register and record the death, issue a burial permit and acknowledgement of registration
of the death, provide certified copies, certificates, search notices, photocopies, and for statistical, research, medical, law
enforcement, adoption and adoption disclosure purposes as applicable. Questions about this collection should be directed
to: The Chief Coroner, 26 Grenville St., Toronto ON M7A 2G9. Telephone: 416 314-4000 or Toll Free: 1 877 991-9959.
0125E (2011/09) © Queen’s Printer for Ontario, 2011
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