Panchayat:Repo18/vol2-page0404
(See Rule 5]
STILL BIRTH REPORT FORM
Still Birth Report
Legal Information This part to be added to the Still Birth Register
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Still Birth Report Statistical Information
This part to be detached and sent fo
statistical processing
In the case of multiple births, fill in a separate
form for each child and write 'Twin birth'
Tor 'Triple birth’ etc., as the case may be,
in the remarks column in the box below left.
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To be filled by the informant Date of Birth: (Enter the exact day, month and year e.g. 1-1-2000) 1. Hospital/ :Institution Name
2. House
Address: (After completing all columns 1 to 12, informant will put date and signature here.)Date: Signature of left thumb marks of the informant
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To be filled by the informant 7. Town or Village of Residence of the mother: (Place where the mother usually lives. This can be
different from the place where the delivery occured. The house address is not required to be entered.) |
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 To be filled by the Registrar
Name : Code No. Registration No: Registration Date District: Date of Birth: Name and Signature of the Registrar
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ഈ താൾ 2018 -ലെ പഞ്ചായത്ത് റെപ്പോ നിർമ്മാണം യജ്ഞത്തിന്റെ ഭാഗമായി സൃഷ്ടിച്ചതാണ്. |