FORM - 2
[see Rule No 5]
DEATH REPORT FORM
| Death Report Legal Information This part to be added to the
Death Register
|
Death Report Statistical Information
This part to be detached and sent for
statistical processing
|
|
To be filled by the informant
1.Date of Death: (Enter the exact day, month and year the death took place e.g.1-1-2000)
Name of the deceased: (Full name as usually written)
(a) Permanent address of the deceased:
(b) Name of the father/husband: *[(C) Name of mother
(d) Address of the deceased at the time
of the death.] Sex of the deceased: (Enter 'Male' or “Female': do not use abbreviation) Age of the deceased (If the deceased was over 1 year of age, give age in completed years. If the deceased was below 1 year of age, give age in months, and if below 1 month give age in completed number of days, and if below one day, in hours.)
Place of death: (Tick the appropriate entry 1, 2 or 3 below and give the name of the Hospital/ Institution or the address of the house where the death took-place). If other place, give location
1. Hospital institution Name:
2. House: Address: 3. Other Place:
Informant's name:
1. Address:
2. Counter signature and seal of the
authorities concerned (in the case of
hospitals/institutions) (After completing all columns 1 to 17 informant will put date and signature here:) Date
Signature or left thumb mark of the informant
|
To be filled by the informant
7. Town or Village of Residence of the
deceased: (Place where the deceased actually lived. This can be different from the place where the death occured. The house address is not required to be entered.) (a) Name of Town/Village: (b) Is it a town of village: (Tick the appro priate entry below)
1. Town:
2. Village:
(C) Name of District: (
d) Name of State:
Religion
(Tick the appropriate entry below 1. Hindu 2. Muslim 3. Christian 4. Any other religion
(write name of the religion)
9. Occupation of the deceased:
(If no occupation write 'Nil')
10. Type of the Medical attention received
before death (Tick the appropriate entry below)
|
To be filled by the informant
1. Institutional
2. Medical attention other than institution
3. No medical attention 11. Was the cause of death medically
certified? (Tick the appropriate entry below) 1. Yes
2. No
12. Name of Disease or Actual Cause of
Death: (For all deaths irrespective of
whether medically certified or not)
13. In case this is a female death, did the
Death occur while pregnant, at the time of delivery or within 6 weeks after the end of pregnancy (Tick the appropriate entry below) 1. Yes
2. No
14. If used to habitually smoke for how many
years?
15. If used to habitually chew tobacco in any
form - for how many years?
16. If used to habitually chew arecanut in any form (including pan masala) - for how many years?
17. If used habitually drink alcohol - for how many years? (Columns to be filled are over, Now put signature at left)
|
| To be filled by the Registrar Registration No: Registration Date: Registration Unit: Town/Village
District: Remarks: (if any)
Name and Signature of the Registrar
|
To be filled by the Registrar Name
Code No. District: Tahsil: Town/Village: Registration Unit: Registration No.:
Registration Date:
|
To be filled by the Registrar Date of Death: Sex: 1. Male
2. Female Age:
Years/Months/Days/Hours Place of Birth: 1. Hospital/Institution
2. House 3. Other Place Name and Signature of the Registrar
|
വർഗ്ഗം:റെപ്പോയിൽ സൃഷ്ടിക്കപ്പെട്ട ലേഖനങ്ങൾ
