Panchayat:Repo18/vol2-page0405
Ward No. .................. on ....................... at .......................... A.M./P.M.
Name of Deceased | For use of Statistical office | |||||
Age of Death | ||||||
Sex | In one year or more, age I years | If less than one year, age in month | If less than one month, age in days | If less than on day, age in hours | ||
1 | Male | |||||
2 | ||||||
Cause of death | ||||||
I. | Immediate cause.State the desease, injury or complication which caused death , not the mode of dying such as heart failure , asthenia etc. Atecedent cause | a)………………………………………………...due to ( or as a consequences of) | ||||
Morbid conditions , if any giving rise to the above cause, stataing underlying conditions last. | b)………………...……………………………..due to (or as a consequences of) | |||||
II. | Other significant conditions contributing to the death count not related to the disease or conditions causing it | c)…………………………………………………………………………………………………………………… | ||||
Manner of death How did injury occur? | ||||||
1) Natural 2)Accident 3) Suicide 4)Homicide 5)Pending investigation | ||||||
If deseased was a female, was pregnancy the death associated with? (1) Yes (2) No If Yes , was there a delivery (1) Yes (2) No | ||||||
Name and sgnature of the Medical attendant clarifying the cause of death Date of verification....... | ||||||
See Reverse for Instructions | ||||||
(To be attached and handed over to the relative of the deseased) | ||||||
Certified that Shri/Smt/Kum………………………………………………………S/W/D of ……………………..….…..R/O …………………………………………………………………was admitted dto this hospital on …………………………..and expired on …………………………………………………….. | ||||||
Doctor | ||||||
Medical Supt . Name of Hospital |