坟场及火葬场组 CEMETERIES & CREMATORIA SECTION 申请加放灵灰瓮 APPLICATION FOR PLACING ADDITIONAL URN(S) (甲部) 有关加放灵灰瓮的详情 (Section A) Particulars of Additional Urn(s) Under Application 灵灰安置所 Columbarium: ? 哥连臣角 ? 钻石山 ? 富山 ? 葵涌 Cape Collinson Diamond Hill Fu Shan Kwai Chung ? 和合石 ? 长洲 ? 南丫岛 ? 坪洲 请只填选一项. Please tick one item only. Wo Hop Shek Cheung Chau Lamma Island Peng Chau 灵灰龛 Niche: ? 标准 (可安放多过二位先人灵灰;龛位大小會因个别场地而有所不同 Standard (can hold the ashes of more than two deceased persons;the size of niche will differ depending on individual venue) 请只填选一项. Please tick one item only. ? 大型 (可安放多过四位先人灵灰;龛位大小會因个别场地而有所不同) Large (can hold the ashes of more than 4 deceased persons;the size of niche will differ depending on individual venue) 灵灰安置所期号:灵灰龛编号: Columbarium Phase No. Niche No. 已存放在此龛内各灵灰瓮的详情(请将最早安放在此龛内的先人姓名填写在 1) Particulars of deceased person(s) whose cremated ashes is(are) already placed in the niche (Please provide in 1 the name of the deceased whose ashes were first placed in the niche) 先人姓名 Name of Deceased 性别 Sex of Deceased 与申请人关系 Relationship with Applicant 1 2 3 (乙部) 申请人及先人资料 (Section B) Particulars of Applicant and Deceased 申请人资料 Particulars of Applicant 申请人姓名:(中文) (英文) (先生/女士*) Name of Applicant (Chinese) English (Mr./Ms.*) 中文电码: 香港身分证/护照*号码: Chinese Commercial Code HKID Card/Passport* No. 电话号码: 流动电话号码: Tel. No. Mobile Phone No. 联络地址: Correspondence Address 本署可为先人在「无尽思念」网站免费开设个人纪念网页(请参阅注意事项第 3 项).如欲获得以上服务,请提供电邮地址及表示同 意如下: The Department may create a dedicated memorial webpage for the deceased at the Internet Memorial Service free of charge (please read Note 3). If you wish to receive the service, please provide your email address and indicate consent below: ? 电邮地址: 本人同意使用我的电邮地址作上述用途. I agree to the use of my email address for the above purpose. Email Address 请在适当方格内填上「9」号.Please tick the appropriate box(es). * 请删去不适用者.Please delete where appropriate. 请於背页签署.Please sign overleaf. FEHB 136A (12/2013) 1 新安放先人灵灰资料 Particulars of Additional Cremated Ashes to be Placed [1] 先人姓名 Name of Deceased [2] 先人姓名 Name of Deceased [3] 先人姓名 Name of Deceased 其他先人 (请注明) Other Deceased (Please specify) 性别 Sex 去世时年龄 Age at Death 死亡日期 Date of Death (日DD/月MM/年YYYY) 香港身分证/护照*号码(如有) HKID Card/Passport* No. (if any) 火葬场地点 Crematorium 火葬日期 Date of Cremation (日DD/月MM/年YYYY) 火葬许可证/令*编号 Cremation Permit/Order* No. 与申请人关系 Relationship with Applicant 与(甲部)先人 1 关系 Relationship with Deceased 1 in Section A (丙部) 申请人声明 (Section C) Declaration by Applicant 谨此声明,就本人所知所信,在本申请表所填报的资料,均属确实无讹.本人明白,如填报的资料经查明失实,本 申请将不获批准,如已获批准亦将會被撤回. I declare that to the best of my knowledge and belief all the information contained in this application form is true and correct. I understand that no permission will be given or such permission if given will be revoked if I have made a false declaration. 日期: / / Date 日DD 月MM 年YYYY 申请人签署 Signature of Applicant * 请删去不适用者.Please delete where appropriate. 此栏只供办事处填写 FOR OFFICE USE ONLY 查核人员: Verified by 档案编号: 收據编号: Transaction Ref. No. Receipt No. 日期: / / Date 日DD 月MM 年YYYY 查核人员签署 Signature of FEHD Officer 查核人员姓名及职位 Name and Post Title 核准人员: Approved by 日期: / / Date 日DD 月MM 年YYYY 核准人员签署 Signature of Approving Officer 核准人员姓名及职位 Name and Post Title FEHB 136A (12/2013) 2 FEHB 136A (12/2013) 3 注意事项 Notes 1. 本表格不收费用. No fee is charged for this form. 2. 申请人与食物环境衞生署(食环署)进行任何事务往来时,均不得向食环署人员提供任何利益. Applicants, while having dealings of any kind with the Food and Environmental Hygiene Department (FEHD), should not offer any advantage to the FEHD officers. 3. 申请人必须填写本表格的甲及乙部. Applicant should complete Sections A and B of this form. 申请人可为先人在「无尽思念」网站(memorial.gov.hk)开设纪念网页.申请人只需填写电邮地址,本署會预设一个 载有其先人姓名及去世日期的个人纪念网页,并於加放灵灰瓮后两个工作天内发出确认通知电邮,以便申请人随 时啓动户口及登入纪念网页编辑网页内容.网上追思服务费用全免.如申请人已用相同的电邮地址为同一先人於 「无尽思念」网站开设纪念网页,则不會重复开设网页. Applicant interested in creating a memorial webpage at the Internet Memorial Service (memorial.gov.hk) for the deceased only needs to provide his/her email address. The Department will prepare a dedicated memorial webpage with the name and date of death of the deceased. A notification email for confirmation will be issued within two working days after additional urn(s). The applicant may then activate the account, login the webpage and edit the contents at any time. The Internet Memorial Service is free of charge. If a memorial webpage at the Internet Memorial Service has already been created for the same deceased by the applicant using the same email address, no additional webpage will be created. 4. 丙部须由申请人亲自签署,否则本申请将被视作无效.申请人如不懂签名,则须在高级衞生督察 (坟场及火葬场) 、 衞生督察(坟场及火葬场)或高级管工(坟场及火葬场)面前画上记号. Section C must be signed by the applicant personally, otherwise this application will be treated as null and void. If the applicant is unable to sign the application, he/she is required to attend either before the Senior Health Inspector (C&C), Health Inspector (C&C) or Senior Foreman (C&C) to make his/her mark. 5. 在可行情况下,每个标准及大型灵灰龛位可分别安放多过两位及四位先人灵灰,但加放灵灰在灵灰龛的先人必须 是最早安放在灵灰龛内的先人的近亲或与其有密切关系的.近亲指配偶、父母、祖父母、外祖父母、兄弟、姊妹、 配偶的父亲、配偶的母亲、媳妇、女婿,或父系或母系的直系后裔. Each standard and large niche can hold the ashes of more than two and four deceased persons respectively as far as situation warrants. Provided that the subsequent set of cremated human ashes deposited in a niche shall be those of a close relative of or in close relationship with the deceased first deposited in that niche. Close relative means the spouse, parent, grandparent, grandparent-in-law, brother, sister, father-in-law, mother-in-law, daughter-in-law, son-in-law or a direct descendant of either the male or female line. 6. 每次加放先人灵灰的收费为 140 元.有关费用會?时调整,以付款当日的规定收费为准.已缴费用,恕不退还. The fee for placing additional urn(s) is $140 each time. The respective fee may be adjusted from time to time and charged according to the prevailing prescribed fee on the day of payment. Fees paid are not refundable. 7. 申请人必须为该灵灰龛的持证人,并须带备下列文件亲自到食环署香港(跑马地)或九龙(红磡)坟场及火葬场 办事处办理.须出示的文件: (i) 申请人的香港身分证正本及副本一份; (ii) 加灰的先人「?取骨灰许可证」正本及副本一份(如先人非在港火化,申请人须出示外地合法火葬场发出的 火化文件.如有?取骨灰许可证及死亡证,亦须一同提交) ; (iii) 加灰的先人与该灵灰龛内原有先人的关系证明文件正副本(如无法提供则可在本处宣誓) ;以及 (iv) 如申请离岛的灵灰龛则另须带备离岛乡事委员會的证明信,以证明该先人合乎资格. The applicant, who must be the original permittee of the niche, shall bring along the following documents and apply in person at the Cemeteries and Crematoria Office of FEHD in Hong Kong (Happy Valley) or Kowloon (Hung Hom). Documents to be produced: (i) the original and a copy of the HKID Card of the applicant; (ii) the original and copy of the "Permit to Take Away Cremated Ashes" of the deceased (If the deceased was not cremated in Hong Kong, cremation documents issued by an overseas legal crematorium are required. Permit to Take Away Cremated Ashes and death certificate, if any, should be produced); (iii) the original and copy of the documentary proof of relationship between the deceased whose ashes will be deposited and the deceased whose ashes have already been deposited. If such proof is not available, the applicant shall take an oath at the above office; and (iv) for application for niches on outlying islands, a letter from the relevant islands rural committee is required to certify the eligibility of the deceased. 8. 一般查询 如有任何查询,可致电或传真至: 港岛办事处 - 跑马地黄泥涌道一号 J(香港坟场侧) 电话号码:2570 4318 传真号码:2591 1879 FEHB 136A (12/2013) 4 九龙及新界办事处 - 红磡畅行道 6 号地下高层 电话号码:2365 5321 传真号码:2176 4963 General Enquiry For enquiries concerning the application, please call or fax to: Hong Kong Office - 1J, Wong Nai Chung Road, Happy Valley. Tel.No. : 2570 4318 (Next to Hong Kong Cemetery) Fax No. : 2591 1879 Kowloon & NT Office - Upper Ground Floor, Tel.No. : 2365 5321 6, Cheong Hang Road, Hung Hom. Fax No. : 2176 4963 9 收集个人资料声明 Personal Information Collection Statement (i) 食环署會利用经本表格所提供的个人资料,处理轄下坟场及火葬场服务的申请事宜.提供个人资料与否,纯 属自愿性质,但在资料不足的情况下,则恐怕不能处理有关的申请. The personal data provided by means of this form will be used by FEHD for purposes relating to applications for cemeteries and crematoria services. The provision of personal data by means of this form is voluntary. However, if the applicant does not provide sufficient information, we may not be able to process the application. (ii) 本表格内所提供的个人资料,可能會被转交其他政府部门或机构,以达致上文第 8(i)段所载的目的. The personal data provided by means of this form may be disclosed to other Government Departments and Agencies in pursuance of the purposes mentioned in paragraph 8(i) above. (iii) 根據《个人资料(私隐)条例》第18 条、第22 条及附表 1 内第 6 原则的规定,申请人有权查阅及更正他/ 她的个人资料.查阅的权利包括有权索取本表格内所提供的个人资料副本一份. The applicant has a right of access and correction with respect to personal data as provided for in accordance with Sections 18 and 22 and Principle 6 of Schedule I of the Personal Data (Privacy) Ordinance. His/her right of access includes the right to obtain a copy of his/her personal data which he/she has provided by means of this form. (iv) 如对经由本表格提供个人资料一事有任何疑问,包括查阅及更正个人资料等,可向本署高级衞生督察(坟场 及火葬场)提出,地址为: 港岛办事处 - 跑马地黄泥涌道一号 J(香港坟场侧) 电话号码:2578 9406 九龙及新界办事处 - 红磡畅行道 6 号地下高层 电话号码:2364 5405 Enquiries concerning the personal data collected by means of this form, including the making of access and corrections, should be addressed to the Senior Health Inspector (Cemeteries and Crematoria) at : Hong Kong Office - 1J, Wong Nai Chung Road, Happy Valley. (Next to Hong Kong Cemetery) Tel.No.: 2578 9406 Kowloon & NT Office - Upper Ground Floor, 6, Cheong Hang Road, Hung Hom. Tel.No.: 2364 5405
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坟场及火葬场组 CEMETERIES & CREMATORIA SECTION 申请加放灵灰瓮 APPLICATION FOR PLACING ADDITIONAL URN(S) (甲部) 有关加放灵灰瓮的详情 (Section A) Particulars of Additional Urn(s) Under Application 灵灰安置所 Columbarium: ? 哥连臣角 ? 钻石山 ? 富山 ? 葵涌 Cape Collinson Diamond Hill Fu Shan Kwai Chung ? 和合石 ? 长洲 ? 南丫岛 ? 坪洲 请只填选一项. Please tick one item only. Wo Hop Shek Cheung Chau Lamma Island Peng Chau 灵灰龛 Niche: ? 标准 (可安放多过二位先人灵灰;龛位大小會因个别场地而有所不同 Standard (can hold the ashes of more than two deceased persons;the size of niche will differ depending on individual venue) 请只填选一项. Please tick one item only. ? 大型 (可安放多过四位先人灵灰;龛位大小會因个别场地而有所不同) Large (can hold the ashes of more than 4 deceased persons;the size of niche will differ depending on individual venue) 灵灰安置所期号:灵灰龛编号: Columbarium Phase No. Niche No. 已存放在此龛内各灵灰瓮的详情(请将最早安放在此龛内的先人姓名填写在 1) Particulars of deceased person(s) whose cremated ashes is(are) already placed in the niche (Please provide in 1 the name of the deceased whose ashes were first placed in the niche) 先人姓名 Name of Deceased 性别 Sex of Deceased 与申请人关系 Relationship with Applicant 1 2 3 (乙部) 申请人及先人资料 (Section B) Particulars of Applicant and Deceased 申请人资料 Particulars of Applicant 申请人姓名:(中文) (英文) (先生/女士*) Name of Applicant (Chinese) English (Mr./Ms.*) 中文电码: 香港身分证/护照*号码: Chinese Commercial Code HKID Card/Passport* No. 电话号码: 流动电话号码: Tel. No. Mobile Phone No. 联络地址: Correspondence Address 本署可为先人在「无尽思念」网站免费开设个人纪念网页(请参阅注意事项第 3 项).如欲获得以上服务,请提供电邮地址及表示同 意如下: The Department may create a dedicated memorial webpage for the deceased at the Internet Memorial Service free of charge (please read Note 3). If you wish to receive the service, please provide your email address and indicate consent below: ? 电邮地址: 本人同意使用我的电邮地址作上述用途. I agree to the use of my email address for the above purpose. Email Address 请在适当方格内填上「9」号.Please tick the appropriate box(es). * 请删去不适用者.Please delete where appropriate. 请於背页签署.Please sign overleaf. FEHB 136A (12/2013) 1 新安放先人灵灰资料 Particulars of Additional Cremated Ashes to be Placed [1] 先人姓名 Name of Deceased [2] 先人姓名 Name of Deceased [3] 先人姓名 Name of Deceased 其他先人 (请注明) Other Deceased (Please specify) 性别 Sex 去世时年龄 Age at Death 死亡日期 Date of Death (日DD/月MM/年YYYY) 香港身分证/护照*号码(如有) HKID Card/Passport* No. (if any) 火葬场地点 Crematorium 火葬日期 Date of Cremation (日DD/月MM/年YYYY) 火葬许可证/令*编号 Cremation Permit/Order* No. 与申请人关系 Relationship with Applicant 与(甲部)先人 1 关系 Relationship with Deceased 1 in Section A (丙部) 申请人声明 (Section C) Declaration by Applicant 谨此声明,就本人所知所信,在本申请表所填报的资料,均属确实无讹.本人明白,如填报的资料经查明失实,本 申请将不获批准,如已获批准亦将會被撤回. I declare that to the best of my knowledge and belief all the information contained in this application form is true and correct. I understand that no permission will be given or such permission if given will be revoked if I have made a false declaration. 日期: / / Date 日DD 月MM 年YYYY 申请人签署 Signature of Applicant * 请删去不适用者.Please delete where appropriate. 此栏只供办事处填写 FOR OFFICE USE ONLY 查核人员: Verified by 档案编号: 收據编号: Transaction Ref. No. Receipt No. 日期: / / Date 日DD 月MM 年YYYY 查核人员签署 Signature of FEHD Officer 查核人员姓名及职位 Name and Post Title 核准人员: Approved by 日期: / / Date 日DD 月MM 年YYYY 核准人员签署 Signature of Approving Officer 核准人员姓名及职位 Name and Post Title FEHB 136A (12/2013) 2 FEHB 136A (12/2013) 3 注意事项 Notes 1. 本表格不收费用. No fee is charged for this form. 2. 申请人与食物环境衞生署(食环署)进行任何事务往来时,均不得向食环署人员提供任何利益. Applicants, while having dealings of any kind with the Food and Environmental Hygiene Department (FEHD), should not offer any advantage to the FEHD officers. 3. 申请人必须填写本表格的甲及乙部. Applicant should complete Sections A and B of this form. 申请人可为先人在「无尽思念」网站(memorial.gov.hk)开设纪念网页.申请人只需填写电邮地址,本署會预设一个 载有其先人姓名及去世日期的个人纪念网页,并於加放灵灰瓮后两个工作天内发出确认通知电邮,以便申请人随 时啓动户口及登入纪念网页编辑网页内容.网上追思服务费用全免.如申请人已用相同的电邮地址为同一先人於 「无尽思念」网站开设纪念网页,则不會重复开设网页. Applicant interested in creating a memorial webpage at the Internet Memorial Service (memorial.gov.hk) for the deceased only needs to provide his/her email address. The Department will prepare a dedicated memorial webpage with the name and date of death of the deceased. A notification email for confirmation will be issued within two working days after additional urn(s). The applicant may then activate the account, login the webpage and edit the contents at any time. The Internet Memorial Service is free of charge. If a memorial webpage at the Internet Memorial Service has already been created for the same deceased by the applicant using the same email address, no additional webpage will be created. 4. 丙部须由申请人亲自签署,否则本申请将被视作无效.申请人如不懂签名,则须在高级衞生督察 (坟场及火葬场) 、 衞生督察(坟场及火葬场)或高级管工(坟场及火葬场)面前画上记号. Section C must be signed by the applicant personally, otherwise this application will be treated as null and void. If the applicant is unable to sign the application, he/she is required to attend either before the Senior Health Inspector (C&C), Health Inspector (C&C) or Senior Foreman (C&C) to make his/her mark. 5. 在可行情况下,每个标准及大型灵灰龛位可分别安放多过两位及四位先人灵灰,但加放灵灰在灵灰龛的先人必须 是最早安放在灵灰龛内的先人的近亲或与其有密切关系的.近亲指配偶、父母、祖父母、外祖父母、兄弟、姊妹、 配偶的父亲、配偶的母亲、媳妇、女婿,或父系或母系的直系后裔. Each standard and large niche can hold the ashes of more than two and four deceased persons respectively as far as situation warrants. Provided that the subsequent set of cremated human ashes deposited in a niche shall be those of a close relative of or in close relationship with the deceased first deposited in that niche. Close relative means the spouse, parent, grandparent, grandparent-in-law, brother, sister, father-in-law, mother-in-law, daughter-in-law, son-in-law or a direct descendant of either the male or female line. 6. 每次加放先人灵灰的收费为 140 元.有关费用會?时调整,以付款当日的规定收费为准.已缴费用,恕不退还. The fee for placing additional urn(s) is $140 each time. The respective fee may be adjusted from time to time and charged according to the prevailing prescribed fee on the day of payment. Fees paid are not refundable. 7. 申请人必须为该灵灰龛的持证人,并须带备下列文件亲自到食环署香港(跑马地)或九龙(红磡)坟场及火葬场 办事处办理.须出示的文件: (i) 申请人的香港身分证正本及副本一份; (ii) 加灰的先人「?取骨灰许可证」正本及副本一份(如先人非在港火化,申请人须出示外地合法火葬场发出的 火化文件.如有?取骨灰许可证及死亡证,亦须一同提交) ; (iii) 加灰的先人与该灵灰龛内原有先人的关系证明文件正副本(如无法提供则可在本处宣誓) ;以及 (iv) 如申请离岛的灵灰龛则另须带备离岛乡事委员會的证明信,以证明该先人合乎资格. The applicant, who must be the original permittee of the niche, shall bring along the following documents and apply in person at the Cemeteries and Crematoria Office of FEHD in Hong Kong (Happy Valley) or Kowloon (Hung Hom). Documents to be produced: (i) the original and a copy of the HKID Card of the applicant; (ii) the original and copy of the "Permit to Take Away Cremated Ashes" of the deceased (If the deceased was not cremated in Hong Kong, cremation documents issued by an overseas legal crematorium are required. Permit to Take Away Cremated Ashes and death certificate, if any, should be produced); (iii) the original and copy of the documentary proof of relationship between the deceased whose ashes will be deposited and the deceased whose ashes have already been deposited. If such proof is not available, the applicant shall take an oath at the above office; and (iv) for application for niches on outlying islands, a letter from the relevant islands rural committee is required to certify the eligibility of the deceased. 8. 一般查询 如有任何查询,可致电或传真至: 港岛办事处 - 跑马地黄泥涌道一号 J(香港坟场侧) 电话号码:2570 4318 传真号码:2591 1879 FEHB 136A (12/2013) 4 九龙及新界办事处 - 红磡畅行道 6 号地下高层 电话号码:2365 5321 传真号码:2176 4963 General Enquiry For enquiries concerning the application, please call or fax to: Hong Kong Office - 1J, Wong Nai Chung Road, Happy Valley. Tel.No. : 2570 4318 (Next to Hong Kong Cemetery) Fax No. : 2591 1879 Kowloon & NT Office - Upper Ground Floor, Tel.No. : 2365 5321 6, Cheong Hang Road, Hung Hom. Fax No. : 2176 4963 9 收集个人资料声明 Personal Information Collection Statement (i) 食环署會利用经本表格所提供的个人资料,处理轄下坟场及火葬场服务的申请事宜.提供个人资料与否,纯 属自愿性质,但在资料不足的情况下,则恐怕不能处理有关的申请. The personal data provided by means of this form will be used by FEHD for purposes relating to applications for cemeteries and crematoria services. The provision of personal data by means of this form is voluntary. However, if the applicant does not provide sufficient information, we may not be able to process the application. (ii) 本表格内所提供的个人资料,可能會被转交其他政府部门或机构,以达致上文第 8(i)段所载的目的. The personal data provided by means of this form may be disclosed to other Government Departments and Agencies in pursuance of the purposes mentioned in paragraph 8(i) above. (iii) 根據《个人资料(私隐)条例》第18 条、第22 条及附表 1 内第 6 原则的规定,申请人有权查阅及更正他/ 她的个人资料.查阅的权利包括有权索取本表格内所提供的个人资料副本一份. The applicant has a right of access and correction with respect to personal data as provided for in accordance with Sections 18 and 22 and Principle 6 of Schedule I of the Personal Data (Privacy) Ordinance. His/her right of access includes the right to obtain a copy of his/her personal data which he/she has provided by means of this form. (iv) 如对经由本表格提供个人资料一事有任何疑问,包括查阅及更正个人资料等,可向本署高级衞生督察(坟场 及火葬场)提出,地址为: 港岛办事处 - 跑马地黄泥涌道一号 J(香港坟场侧) 电话号码:2578 9406 九龙及新界办事处 - 红磡畅行道 6 号地下高层 电话号码:2364 5405 Enquiries concerning the personal data collected by means of this form, including the making of access and corrections, should be addressed to the Senior Health Inspector (Cemeteries and Crematoria) at : Hong Kong Office - 1J, Wong Nai Chung Road, Happy Valley. (Next to Hong Kong Cemetery) Tel.No.: 2578 9406 Kowloon & NT Office - Upper Ground Floor, 6, Cheong Hang Road, Hung Hom. Tel.No.: 2364 5405