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I __________________, of ____________________, being the relative [or friend, or legal representative, as the case may be, describing the relation if a relative,] having the charge of or being responsible for the burial of A.B., of ________________, who died at _____________in the parish of , on the _____________day of _______________________, do hereby give you notice that it is intended by me that the body of the said A.B. shall be buried within the [here describe the churchyard or graveyard in which the body is to be buried,'] on the ________________day of _______________________'", at the hour of, without the performance in the manner prescribed by law of the service for the burial of the dead according to the rites of the Church of England, and I give this notice pursuant to the Burial Laws Amendment Act, 1880. To the Rector [or, as the case may be,] of ________________________.
To the Rector [or, as the case may be,] of ___________________________.
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