http://panchayatwiki.lsgkerala.gov.in/index.php?action=history&feed=atom&title=Panchayat%3ARepo18%2Fvol2-page0405 2026-04-13T10:08:17Z Revision history for this page on the wiki MediaWiki 1.40.1 http://panchayatwiki.lsgkerala.gov.in/index.php?title=Panchayat:Repo18/vol2-page0405&diff=8894&oldid=prev 2019-01-24T07:22:11Z

<p></p> <table style="background-color: #fff; color: #202122;" data-mw="interface"> <col class="diff-marker" /> <col class="diff-content" /> <col class="diff-marker" /> <col class="diff-content" /> <tr class="diff-title" lang="en"> <td colspan="2" style="background-color: #fff; color: #202122; text-align: center;">← Older revision</td> <td colspan="2" style="background-color: #fff; color: #202122; text-align: center;">Revision as of 07:22, 24 January 2019</td> </tr><tr><td colspan="2" class="diff-lineno" id="mw-diff-left-l5">Line 5:</td> <td colspan="2" class="diff-lineno">Line 5:</td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Ward No. .................. on ....................... at .......................... A.M./P.M.&lt;/center&gt;</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Ward No. .................. on ....................... at .......................... A.M./P.M.&lt;/center&gt;</div></td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>----</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>----</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Name of Deceased For use of</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">{| class="wikitable"</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Age <del style="font-weight: bold; text-decoration: none;">at </del>Death <del style="font-weight: bold; text-decoration: none;">Statistical Office </del>Sex <del style="font-weight: bold; text-decoration: none;">If </del>one year |If <del style="font-weight: bold; text-decoration: none;">leSS than lf less than lf </del>less than <del style="font-weight: bold; text-decoration: none;">or more, age </del>one year, one month, <del style="font-weight: bold; text-decoration: none;">one </del>day, <del style="font-weight: bold; text-decoration: none;">in Years </del>age in <del style="font-weight: bold; text-decoration: none;">months age in Days age in Hours</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>Name of Deceased <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </ins>For use of <ins style="font-weight: bold; text-decoration: none;">Statistical office</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>1<del style="font-weight: bold; text-decoration: none;">. </del>Male 2<del style="font-weight: bold; text-decoration: none;">. Female</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">Interval betWeen on set &amp; death approx.</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  ||  || </ins>Age <ins style="font-weight: bold; text-decoration: none;">of </ins>Death <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Cause of <del style="font-weight: bold; text-decoration: none;">Death</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>I. Immediate <del style="font-weight: bold; text-decoration: none;">Cause </del>State the <del style="font-weight: bold; text-decoration: none;">disease</del>, injury or <del style="font-weight: bold; text-decoration: none;">Complication </del>which caused death, not the mode of dying such as heart failure, asthenia<del style="font-weight: bold; text-decoration: none;">, </del>etc. <del style="font-weight: bold; text-decoration: none;">Antecedent </del>cause Morbid conditions, if any<del style="font-weight: bold; text-decoration: none;">, </del>giving rise to the above cause, <del style="font-weight: bold; text-decoration: none;">stating </del>underlying conditions last.</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  || </ins>Sex <ins style="font-weight: bold; text-decoration: none;">|| In </ins>one year <ins style="font-weight: bold; text-decoration: none;">or more, age I years |</ins>| If less than one year, <ins style="font-weight: bold; text-decoration: none;">age in month || If less than </ins>one month, <ins style="font-weight: bold; text-decoration: none;">age in days || If less than on </ins>day, age in <ins style="font-weight: bold; text-decoration: none;">hours || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>.....<del style="font-weight: bold; text-decoration: none;">................................................</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">(a)</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>1 <ins style="font-weight: bold; text-decoration: none;">|| </ins>Male <ins style="font-weight: bold; text-decoration: none;"> ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>due to (or as a consequences of)</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">(b) due to (or as a consequences of)</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>2 <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>II. Other significant conditions contributing to the death <del style="font-weight: bold; text-decoration: none;">but </del>not related to the disease or conditions causing it</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">• • • • • • • • • • • • • • • • • • • • • • • • • •</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  || </ins>Cause of <ins style="font-weight: bold; text-decoration: none;">death ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">.................................</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Manner of <del style="font-weight: bold; text-decoration: none;">Death (</del>1) Natural <del style="font-weight: bold; text-decoration: none;">(</del>2) Accident <del style="font-weight: bold; text-decoration: none;">(</del>3) Suicide <del style="font-weight: bold; text-decoration: none;">(</del>5) Pending <del style="font-weight: bold; text-decoration: none;">Investigation</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>I. <ins style="font-weight: bold; text-decoration: none;">|| </ins>Immediate <ins style="font-weight: bold; text-decoration: none;">cause.</ins>State the <ins style="font-weight: bold; text-decoration: none;">desease</ins>, injury or <ins style="font-weight: bold; text-decoration: none;">complication </ins>which caused death , not the mode of dying such as heart failure , asthenia etc. <ins style="font-weight: bold; text-decoration: none;">                              Atecedent </ins>cause <ins style="font-weight: bold; text-decoration: none;">||  ||  || a)………………………………………………...due to ( or as a consequences of) ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>If <del style="font-weight: bold; text-decoration: none;">deceased </del>was a female, was pregnancy the death associated with?</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>If Yes, was there a delivery<del style="font-weight: bold; text-decoration: none;">? </del>(1) Yes</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  || </ins>Morbid conditions , if any giving rise to the above cause, <ins style="font-weight: bold; text-decoration: none;">stataing </ins>underlying conditions last. <ins style="font-weight: bold; text-decoration: none;">||  ||  || b)………………</ins>...<ins style="font-weight: bold; text-decoration: none;">……………………………</ins>..due to (or as a consequences of) <ins style="font-weight: bold; text-decoration: none;">||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">How did the injury occur?</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">(4) Homicide</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>II. <ins style="font-weight: bold; text-decoration: none;">|| </ins>Other significant conditions contributing to the death <ins style="font-weight: bold; text-decoration: none;">count </ins>not related to the disease or conditions causing it <ins style="font-weight: bold; text-decoration: none;">||  ||  || c)…………………………………………………………………………………………………………………… ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>(2) No</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">(1) Yes (2) No</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  || </ins>Manner of <ins style="font-weight: bold; text-decoration: none;">death                                                          How did  injury occur? ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Name and <del style="font-weight: bold; text-decoration: none;">signature </del>of the Medical <del style="font-weight: bold; text-decoration: none;">Attendant certifying </del>the cause of death</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Date of verification</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  || </ins>1) Natural 2)Accident 3) Suicide <ins style="font-weight: bold; text-decoration: none;">4)Homicide </ins>5)Pending <ins style="font-weight: bold; text-decoration: none;">investigation ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">..................................</del>.......</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>See Reverse for Instructions (To be <del style="font-weight: bold; text-decoration: none;">detached </del>and handed over to the relative of the <del style="font-weight: bold; text-decoration: none;">deceased</del>)</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>If <ins style="font-weight: bold; text-decoration: none;">deseased </ins>was a female, was pregnancy the death associated with? <ins style="font-weight: bold; text-decoration: none;">        (1) Yes      (2) No                                                                          </ins>If Yes , was there a delivery <ins style="font-weight: bold; text-decoration: none;">    </ins>(1) Yes <ins style="font-weight: bold; text-decoration: none;">    </ins>(2) No <ins style="font-weight: bold; text-decoration: none;">                                                                  ||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Certified that Shri/Smt<del style="font-weight: bold; text-decoration: none;">.</del>/<del style="font-weight: bold; text-decoration: none;">Kum............................................</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">S</del>/W/D<del style="font-weight: bold; text-decoration: none;">/ </del>of <del style="font-weight: bold; text-decoration: none;">Shri</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|                                          </ins>Name and <ins style="font-weight: bold; text-decoration: none;">sgnature </ins>of the Medical <ins style="font-weight: bold; text-decoration: none;">attendant clarifying </ins>the cause of death Date of verification....... <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>.....<del style="font-weight: bold; text-decoration: none;">...............................................</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">RO .................................. . . . . . . . . . . . . . . Was </del>admitted <del style="font-weight: bold; text-decoration: none;">to </del>this hospital on<del style="font-weight: bold; text-decoration: none;">..................................</del>.. and expired on ..<del style="font-weight: bold; text-decoration: none;">................................................................ </del>Doctor <del style="font-weight: bold; text-decoration: none;">....................................... (</del>Medical <del style="font-weight: bold; text-decoration: none;">Supdt</del>. Name of Hospital<del style="font-weight: bold; text-decoration: none;">)</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  ||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>See Reverse for Instructions <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>(To be <ins style="font-weight: bold; text-decoration: none;">attached </ins>and handed over to the relative of the <ins style="font-weight: bold; text-decoration: none;">deseased</ins>) <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>Certified that Shri/Smt/<ins style="font-weight: bold; text-decoration: none;">Kum………………………………………………………S</ins>/W/D of <ins style="font-weight: bold; text-decoration: none;">……………………</ins>..<ins style="font-weight: bold; text-decoration: none;">…</ins>.<ins style="font-weight: bold; text-decoration: none;">…</ins>..<ins style="font-weight: bold; text-decoration: none;">R/O …………………………………………………………………was </ins>admitted <ins style="font-weight: bold; text-decoration: none;">dto </ins>this hospital on <ins style="font-weight: bold; text-decoration: none;">…………………………</ins>..and expired on <ins style="font-weight: bold; text-decoration: none;">……………………………………………………</ins>.. <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  ||  ||  || </ins>Doctor <ins style="font-weight: bold; text-decoration: none;">||  ||  || </ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  ||  ||  || </ins>Medical <ins style="font-weight: bold; text-decoration: none;">Supt </ins>. <ins style="font-weight: bold; text-decoration: none;">              </ins>Name of Hospital <ins style="font-weight: bold; text-decoration: none;">||  ||  || </ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|}</ins></div></td></tr> </table>

Ratheeshthankappan http://panchayatwiki.lsgkerala.gov.in/index.php?title=Panchayat:Repo18/vol2-page0405&diff=8876&oldid=prev 2019-01-24T07:12:38Z

<p></p> <table style="background-color: #fff; color: #202122;" data-mw="interface"> <col class="diff-marker" /> <col class="diff-content" /> <col class="diff-marker" /> <col class="diff-content" /> <tr class="diff-title" lang="en"> <td colspan="2" style="background-color: #fff; color: #202122; text-align: center;">← Older revision</td> <td colspan="2" style="background-color: #fff; color: #202122; text-align: center;">Revision as of 07:12, 24 January 2019</td> </tr><tr><td colspan="2" class="diff-lineno" id="mw-diff-left-l2">Line 2:</td> <td colspan="2" class="diff-lineno">Line 2:</td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>&lt;center&gt;&#039;&#039;&#039;FORM - 4&#039;&#039;&#039; &lt;/center&gt;</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>&lt;center&gt;&#039;&#039;&#039;FORM - 4&#039;&#039;&#039; &lt;/center&gt;</div></td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>&lt;center&gt;[See Rule 7]&lt;/center&gt;&lt;center&gt; MEDICAL CERTIFICATE OF CAUSE OF DEATH &lt;/center&gt;&lt;center&gt;(Hospital in-patients. Not to be used for still births) &lt;/center&gt;&lt;center&gt;To be sent to Registrar along with Form No. 2 (Death Report)&lt;/center&gt;</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>&lt;center&gt;[See Rule 7]&lt;/center&gt;&lt;center&gt; MEDICAL CERTIFICATE OF CAUSE OF DEATH &lt;/center&gt;&lt;center&gt;(Hospital in-patients. Not to be used for still births) &lt;/center&gt;&lt;center&gt;To be sent to Registrar along with Form No. 2 (Death Report)&lt;/center&gt;</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Name of the Hospital............................................................................ I hereby certify that the person whose particulars are given below died in the hospital in</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">&lt;center&gt;</ins>Name of the Hospital............................................................................ <ins style="font-weight: bold; text-decoration: none;">&lt;/center&gt;&lt;center&gt;</ins>I hereby certify that the person whose particulars are given below died in the hospital in<ins style="font-weight: bold; text-decoration: none;">&lt;br&gt;</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Ward No. .................. <del style="font-weight: bold; text-decoration: none;">On </del>....................... at .......................... A.M./P.M.</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>Ward No. .................. <ins style="font-weight: bold; text-decoration: none;">on </ins>....................... at .......................... A.M./P.M.<ins style="font-weight: bold; text-decoration: none;">&lt;/center&gt;</ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">----</ins></div></td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Name of Deceased For use of</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Name of Deceased For use of</div></td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Age at Death Statistical Office Sex If one year |If leSS than lf less than lf less than or more, age one year, one month, one day, in Years age in months age in Days age in Hours</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Age at Death Statistical Office Sex If one year |If leSS than lf less than lf less than or more, age one year, one month, one day, in Years age in months age in Days age in Hours</div></td></tr> </table>

Ratheeshthankappan http://panchayatwiki.lsgkerala.gov.in/index.php?title=Panchayat:Repo18/vol2-page0405&diff=8873&oldid=prev 2019-01-24T07:11:10Z

<p></p> <table style="background-color: #fff; color: #202122;" data-mw="interface"> <col class="diff-marker" /> <col class="diff-content" /> <col class="diff-marker" /> <col class="diff-content" /> <tr class="diff-title" lang="en"> <td colspan="2" style="background-color: #fff; color: #202122; text-align: center;">← Older revision</td> <td colspan="2" style="background-color: #fff; color: #202122; text-align: center;">Revision as of 07:11, 24 January 2019</td> </tr><tr><td colspan="2" class="diff-lineno" id="mw-diff-left-l1">Line 1:</td> <td colspan="2" class="diff-lineno">Line 1:</td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">405</del></div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><br/></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><br/></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">THE REGISTRATION OF BIRTH &amp; DEATH RULES, 1999 </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">&lt;center&gt;</ins>'''FORM - 4''' <ins style="font-weight: bold; text-decoration: none;">&lt;/center&gt;</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>'''</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">&lt;center&gt;[</ins>See Rule 7<ins style="font-weight: bold; text-decoration: none;">]&lt;/center&gt;&lt;center&gt; </ins>MEDICAL CERTIFICATE OF CAUSE OF DEATH <ins style="font-weight: bold; text-decoration: none;">&lt;/center&gt;&lt;center&gt;</ins>(Hospital in-patients. Not to be used for still births) <ins style="font-weight: bold; text-decoration: none;">&lt;/center&gt;&lt;center&gt;</ins>To be sent to Registrar along with Form No. 2 (Death Report)<ins style="font-weight: bold; text-decoration: none;">&lt;/center&gt;</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>FORM - 4'''  </div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">FORM No. 4 </del>See Rule 7 MEDICAL CERTIFICATE OF CAUSE OF DEATH (Hospital in-patients. Not to be used for still births) To be sent to Registrar along with Form No. 2 (Death Report)</div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Name of the Hospital............................................................................ I hereby certify that the person whose particulars are given below died in the hospital in</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Name of the Hospital............................................................................ I hereby certify that the person whose particulars are given below died in the hospital in</div></td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Ward No. .................. On ....................... at .......................... A.M./P.M.</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Ward No. .................. On ....................... at .......................... A.M./P.M.</div></td></tr> </table>

Ratheeshthankappan http://panchayatwiki.lsgkerala.gov.in/index.php?title=Panchayat:Repo18/vol2-page0405&diff=8867&oldid=prev 2019-01-24T07:09:24Z

<p></p> <table style="background-color: #fff; color: #202122;" data-mw="interface"> <col class="diff-marker" /> <col class="diff-content" /> <col class="diff-marker" /> <col class="diff-content" /> <tr class="diff-title" lang="en"> <td colspan="2" style="background-color: #fff; color: #202122; text-align: center;">← Older revision</td> <td colspan="2" style="background-color: #fff; color: #202122; text-align: center;">Revision as of 07:09, 24 January 2019</td> </tr><tr><td colspan="2" class="diff-lineno" id="mw-diff-left-l7">Line 7:</td> <td colspan="2" class="diff-lineno">Line 7:</td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Name of the Hospital............................................................................ I hereby certify that the person whose particulars are given below died in the hospital in</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Name of the Hospital............................................................................ I hereby certify that the person whose particulars are given below died in the hospital in</div></td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Ward No. .................. On ....................... at .......................... A.M./P.M.</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Ward No. .................. On ....................... at .......................... A.M./P.M.</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">{| class="wikitable collapsible"</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>Name of Deceased For use of</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">! </del>Name of Deceased <del style="font-weight: bold; text-decoration: none;">!!  !!  !!  !!  !!  !! </del>For use of <del style="font-weight: bold; text-decoration: none;">Statistical office</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>Age <ins style="font-weight: bold; text-decoration: none;">at </ins>Death <ins style="font-weight: bold; text-decoration: none;">Statistical Office </ins>Sex <ins style="font-weight: bold; text-decoration: none;">If </ins>one year <ins style="font-weight: bold; text-decoration: none;">|If leSS than lf less than lf less than </ins>or more, age one year, <ins style="font-weight: bold; text-decoration: none;">one </ins>month<ins style="font-weight: bold; text-decoration: none;">, </ins>one <ins style="font-weight: bold; text-decoration: none;">day</ins>, <ins style="font-weight: bold; text-decoration: none;">in Years </ins>age in <ins style="font-weight: bold; text-decoration: none;">months age in Days </ins>age in <ins style="font-weight: bold; text-decoration: none;">Hours</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>1<ins style="font-weight: bold; text-decoration: none;">. </ins>Male 2<ins style="font-weight: bold; text-decoration: none;">. Female</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|  ||  || </del>Age <del style="font-weight: bold; text-decoration: none;">of </del>Death <del style="font-weight: bold; text-decoration: none;">||  ||  ||  || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">Interval betWeen on set &amp; death approx.</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>Cause of <ins style="font-weight: bold; text-decoration: none;">Death</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|  || </del>Sex <del style="font-weight: bold; text-decoration: none;">|| In </del>one year or more, age <del style="font-weight: bold; text-decoration: none;">I years || If less than </del>one year, <del style="font-weight: bold; text-decoration: none;">age in </del>month <del style="font-weight: bold; text-decoration: none;">|| If less than </del>one <del style="font-weight: bold; text-decoration: none;">month</del>, age in <del style="font-weight: bold; text-decoration: none;">days || If less than on day, </del>age in <del style="font-weight: bold; text-decoration: none;">hours || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>I. Immediate <ins style="font-weight: bold; text-decoration: none;">Cause </ins>State the <ins style="font-weight: bold; text-decoration: none;">disease</ins>, injury or <ins style="font-weight: bold; text-decoration: none;">Complication </ins>which caused death, not the mode of dying such as heart failure, asthenia<ins style="font-weight: bold; text-decoration: none;">, </ins>etc. <ins style="font-weight: bold; text-decoration: none;">Antecedent </ins>cause Morbid conditions, if any<ins style="font-weight: bold; text-decoration: none;">, </ins>giving rise to the above cause, <ins style="font-weight: bold; text-decoration: none;">stating </ins>underlying conditions last.</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">................................................</ins>.....</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">| </del>1 <del style="font-weight: bold; text-decoration: none;">|| </del>Male <del style="font-weight: bold; text-decoration: none;"> ||  ||  ||  ||  || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">(a)</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>due to (or as a consequences of)</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">| </del>2 <del style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">(b) due to (or as a consequences of)</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>II. Other significant conditions contributing to the death <ins style="font-weight: bold; text-decoration: none;">but </ins>not related to the disease or conditions causing it</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|  || </del>Cause of <del style="font-weight: bold; text-decoration: none;">death ||  ||  ||  ||  || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">• • • • • • • • • • • • • • • • • • • • • • • • • •</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">.................................</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">| </del>I. <del style="font-weight: bold; text-decoration: none;">|| </del>Immediate <del style="font-weight: bold; text-decoration: none;">cause.</del>State the <del style="font-weight: bold; text-decoration: none;">desease</del>, injury or <del style="font-weight: bold; text-decoration: none;">complication </del>which caused death , not the mode of dying such as heart failure , asthenia etc. <del style="font-weight: bold; text-decoration: none;">                              Atecedent </del>cause <del style="font-weight: bold; text-decoration: none;">||  ||  || a)………………………………………………...due to ( or as a consequences of) ||  || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>Manner of <ins style="font-weight: bold; text-decoration: none;">Death (</ins>1) Natural <ins style="font-weight: bold; text-decoration: none;">(</ins>2) Accident <ins style="font-weight: bold; text-decoration: none;">(</ins>3) Suicide <ins style="font-weight: bold; text-decoration: none;">(</ins>5) Pending <ins style="font-weight: bold; text-decoration: none;">Investigation</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>If <ins style="font-weight: bold; text-decoration: none;">deceased </ins>was a female, was pregnancy the death associated with?</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|  || </del>Morbid conditions , if any giving rise to the above cause, <del style="font-weight: bold; text-decoration: none;">stataing </del>underlying conditions last. <del style="font-weight: bold; text-decoration: none;">||  ||  || b)………………</del>...<del style="font-weight: bold; text-decoration: none;">……………………………</del>..due to (or as a consequences of) <del style="font-weight: bold; text-decoration: none;">||  || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">If Yes, was there a delivery? </ins>(1) Yes</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">How did the injury occur?</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">| </del>II. <del style="font-weight: bold; text-decoration: none;">|| </del>Other significant conditions contributing to the death <del style="font-weight: bold; text-decoration: none;">count </del>not related to the disease or conditions causing it <del style="font-weight: bold; text-decoration: none;">||  ||  || c)…………………………………………………………………………………………………………………… ||  || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">(4) Homicide</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>(2) No</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|  || </del>Manner of <del style="font-weight: bold; text-decoration: none;">death                                                          How did  injury occur? ||  ||  ||  ||  || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>(1) Yes (2) No</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>Name and <ins style="font-weight: bold; text-decoration: none;">signature </ins>of the Medical <ins style="font-weight: bold; text-decoration: none;">Attendant certifying </ins>the cause of death</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|  || </del>1) Natural 2)Accident 3) Suicide <del style="font-weight: bold; text-decoration: none;">4)Homicide </del>5)Pending <del style="font-weight: bold; text-decoration: none;">investigation ||  ||  ||  ||  || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>Date of verification</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">..................................</ins>.......</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">| </del>If <del style="font-weight: bold; text-decoration: none;">deseased </del>was a female, was pregnancy the death associated with? <del style="font-weight: bold; text-decoration: none;">        </del>(1) Yes <del style="font-weight: bold; text-decoration: none;">      </del>(2) No <del style="font-weight: bold; text-decoration: none;">                                                                        If Yes , was there a delivery      </del>(1) Yes <del style="font-weight: bold; text-decoration: none;">    </del>(2) No <del style="font-weight: bold; text-decoration: none;">                                                                  ||  ||  ||  ||  ||  || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>See Reverse for Instructions (To be <ins style="font-weight: bold; text-decoration: none;">detached </ins>and handed over to the relative of the <ins style="font-weight: bold; text-decoration: none;">deceased</ins>)</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div>Certified that Shri/Smt<ins style="font-weight: bold; text-decoration: none;">.</ins>/<ins style="font-weight: bold; text-decoration: none;">Kum............................................</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|                                          </del>Name and <del style="font-weight: bold; text-decoration: none;">sgnature </del>of the Medical <del style="font-weight: bold; text-decoration: none;">attendant clarifying </del>the cause of death Date of verification....... <del style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">S</ins>/W/D<ins style="font-weight: bold; text-decoration: none;">/ </ins>of <ins style="font-weight: bold; text-decoration: none;">Shri</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">....................................................</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|  ||  ||  ||  ||  ||  || </del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">RO .................................. . . . . . . . . . </ins>. . . . . <ins style="font-weight: bold; text-decoration: none;">Was </ins>admitted <ins style="font-weight: bold; text-decoration: none;">to </ins>this hospital on<ins style="font-weight: bold; text-decoration: none;">..................................</ins>.. and expired on ..<ins style="font-weight: bold; text-decoration: none;">................................................................ </ins>Doctor <ins style="font-weight: bold; text-decoration: none;">....................................... (</ins>Medical <ins style="font-weight: bold; text-decoration: none;">Supdt</ins>. Name of Hospital<ins style="font-weight: bold; text-decoration: none;">)</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">| </del>See Reverse for Instructions <del style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </del></div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">| </del>(To be <del style="font-weight: bold; text-decoration: none;">attached </del>and handed over to the relative of the <del style="font-weight: bold; text-decoration: none;">deseased</del>) <del style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </del></div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">| </del>Certified that Shri/Smt/<del style="font-weight: bold; text-decoration: none;">Kum………………………………………………………S</del>/W/D of <del style="font-weight: bold; text-decoration: none;">……………………</del>..<del style="font-weight: bold; text-decoration: none;">…</del>.<del style="font-weight: bold; text-decoration: none;">…</del>..<del style="font-weight: bold; text-decoration: none;">R/O …………………………………………………………………was </del>admitted <del style="font-weight: bold; text-decoration: none;">dto </del>this hospital on <del style="font-weight: bold; text-decoration: none;">…………………………</del>..and expired on <del style="font-weight: bold; text-decoration: none;">……………………………………………………</del>.. <del style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </del></div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|  ||  ||  || </del>Doctor <del style="font-weight: bold; text-decoration: none;">||  ||  || </del></div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|-</del></div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|  ||  ||  || </del>Medical <del style="font-weight: bold; text-decoration: none;">Supt </del>. <del style="font-weight: bold; text-decoration: none;">              </del>Name of Hospital <del style="font-weight: bold; text-decoration: none;">||  ||  || </del></div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">|}</del></div></td><td colspan="2" class="diff-side-added"></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">{{create}}</del></div></td><td colspan="2" class="diff-side-added"></td></tr> </table>

Ratheeshthankappan http://panchayatwiki.lsgkerala.gov.in/index.php?title=Panchayat:Repo18/vol2-page0405&diff=8862&oldid=prev 2019-01-24T07:08:33Z

<p></p> <table style="background-color: #fff; color: #202122;" data-mw="interface"> <col class="diff-marker" /> <col class="diff-content" /> <col class="diff-marker" /> <col class="diff-content" /> <tr class="diff-title" lang="en"> <td colspan="2" style="background-color: #fff; color: #202122; text-align: center;">← Older revision</td> <td colspan="2" style="background-color: #fff; color: #202122; text-align: center;">Revision as of 07:08, 24 January 2019</td> </tr><tr><td colspan="2" class="diff-lineno" id="mw-diff-left-l7">Line 7:</td> <td colspan="2" class="diff-lineno">Line 7:</td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Name of the Hospital............................................................................ I hereby certify that the person whose particulars are given below died in the hospital in</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Name of the Hospital............................................................................ I hereby certify that the person whose particulars are given below died in the hospital in</div></td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Ward No. .................. On ....................... at .......................... A.M./P.M.</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>Ward No. .................. On ....................... at .......................... A.M./P.M.</div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Name of Deceased For use of</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">{| class="wikitable collapsible"</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Age <del style="font-weight: bold; text-decoration: none;">at </del>Death <del style="font-weight: bold; text-decoration: none;">Statistical Office </del>Sex <del style="font-weight: bold; text-decoration: none;">If </del>one year |If <del style="font-weight: bold; text-decoration: none;">leSS than lf less than lf </del>less than <del style="font-weight: bold; text-decoration: none;">or more, age </del>one year, one month, <del style="font-weight: bold; text-decoration: none;">one </del>day, <del style="font-weight: bold; text-decoration: none;">in Years </del>age in <del style="font-weight: bold; text-decoration: none;">months age in Days age in Hours</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">! </ins>Name of Deceased <ins style="font-weight: bold; text-decoration: none;">!!  !!  !!  !!  !!  !! </ins>For use of <ins style="font-weight: bold; text-decoration: none;">Statistical office</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>1<del style="font-weight: bold; text-decoration: none;">. </del>Male 2<del style="font-weight: bold; text-decoration: none;">. Female</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">Interval betWeen on set &amp; death approx.</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  ||  || </ins>Age <ins style="font-weight: bold; text-decoration: none;">of </ins>Death <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Cause of <del style="font-weight: bold; text-decoration: none;">Death</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>I. Immediate <del style="font-weight: bold; text-decoration: none;">Cause </del>State the <del style="font-weight: bold; text-decoration: none;">disease</del>, injury or <del style="font-weight: bold; text-decoration: none;">Complication </del>which caused death, not the mode of dying such as heart failure, asthenia<del style="font-weight: bold; text-decoration: none;">, </del>etc. <del style="font-weight: bold; text-decoration: none;">Antecedent </del>cause Morbid conditions, if any<del style="font-weight: bold; text-decoration: none;">, </del>giving rise to the above cause, <del style="font-weight: bold; text-decoration: none;">stating </del>underlying conditions last.</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  || </ins>Sex <ins style="font-weight: bold; text-decoration: none;">|| In </ins>one year <ins style="font-weight: bold; text-decoration: none;">or more, age I years |</ins>| If less than one year, <ins style="font-weight: bold; text-decoration: none;">age in month || If less than </ins>one month, <ins style="font-weight: bold; text-decoration: none;">age in days || If less than on </ins>day, age in <ins style="font-weight: bold; text-decoration: none;">hours || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">................................................</del>.....</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">(a)</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>1 <ins style="font-weight: bold; text-decoration: none;">|| </ins>Male <ins style="font-weight: bold; text-decoration: none;"> ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>due to (or as a consequences of)</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">(b) due to (or as a consequences of)</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>2 <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>II. Other significant conditions contributing to the death <del style="font-weight: bold; text-decoration: none;">but </del>not related to the disease or conditions causing it</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">• • • • • • • • • • • • • • • • • • • • • • • • • •</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  || </ins>Cause of <ins style="font-weight: bold; text-decoration: none;">death ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">.................................</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Manner of <del style="font-weight: bold; text-decoration: none;">Death (</del>1) Natural <del style="font-weight: bold; text-decoration: none;">(</del>2) Accident <del style="font-weight: bold; text-decoration: none;">(</del>3) Suicide <del style="font-weight: bold; text-decoration: none;">(</del>5) Pending <del style="font-weight: bold; text-decoration: none;">Investigation</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>I. <ins style="font-weight: bold; text-decoration: none;">|| </ins>Immediate <ins style="font-weight: bold; text-decoration: none;">cause.</ins>State the <ins style="font-weight: bold; text-decoration: none;">desease</ins>, injury or <ins style="font-weight: bold; text-decoration: none;">complication </ins>which caused death , not the mode of dying such as heart failure , asthenia etc. <ins style="font-weight: bold; text-decoration: none;">                              Atecedent </ins>cause <ins style="font-weight: bold; text-decoration: none;">||  ||  || a)………………………………………………...due to ( or as a consequences of) ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>If <del style="font-weight: bold; text-decoration: none;">deceased </del>was a female, was pregnancy the death associated with?</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>If Yes, was there a delivery<del style="font-weight: bold; text-decoration: none;">? </del>(1) Yes</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  || </ins>Morbid conditions , if any giving rise to the above cause, <ins style="font-weight: bold; text-decoration: none;">stataing </ins>underlying conditions last. <ins style="font-weight: bold; text-decoration: none;">||  ||  || b)………………</ins>...<ins style="font-weight: bold; text-decoration: none;">……………………………</ins>..due to (or as a consequences of) <ins style="font-weight: bold; text-decoration: none;">||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">How did the injury occur?</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">(4) Homicide</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>II. <ins style="font-weight: bold; text-decoration: none;">|| </ins>Other significant conditions contributing to the death <ins style="font-weight: bold; text-decoration: none;">count </ins>not related to the disease or conditions causing it <ins style="font-weight: bold; text-decoration: none;">||  ||  || c)…………………………………………………………………………………………………………………… ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>(2) No</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">(1) Yes (2) No</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  || </ins>Manner of <ins style="font-weight: bold; text-decoration: none;">death                                                          How did  injury occur? ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Name and <del style="font-weight: bold; text-decoration: none;">signature </del>of the Medical <del style="font-weight: bold; text-decoration: none;">Attendant certifying </del>the cause of death</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Date of verification</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  || </ins>1) Natural 2)Accident 3) Suicide <ins style="font-weight: bold; text-decoration: none;">4)Homicide </ins>5)Pending <ins style="font-weight: bold; text-decoration: none;">investigation ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">..................................</del>.......</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>See Reverse for Instructions (To be <del style="font-weight: bold; text-decoration: none;">detached </del>and handed over to the relative of the <del style="font-weight: bold; text-decoration: none;">deceased</del>)</div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>If <ins style="font-weight: bold; text-decoration: none;">deseased </ins>was a female, was pregnancy the death associated with? <ins style="font-weight: bold; text-decoration: none;">        (1) Yes      (2) No                                                                          </ins>If Yes , was there a delivery <ins style="font-weight: bold; text-decoration: none;">    </ins>(1) Yes <ins style="font-weight: bold; text-decoration: none;">    </ins>(2) No <ins style="font-weight: bold; text-decoration: none;">                                                                  ||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>Certified that Shri/Smt<del style="font-weight: bold; text-decoration: none;">.</del>/<del style="font-weight: bold; text-decoration: none;">Kum............................................</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">S</del>/W/D<del style="font-weight: bold; text-decoration: none;">/ </del>of <del style="font-weight: bold; text-decoration: none;">Shri</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|                                          </ins>Name and <ins style="font-weight: bold; text-decoration: none;">sgnature </ins>of the Medical <ins style="font-weight: bold; text-decoration: none;">attendant clarifying </ins>the cause of death Date of verification....... <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div>.....<del style="font-weight: bold; text-decoration: none;">...............................................</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td class="diff-marker" data-marker="−"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #ffe49c; vertical-align: top; white-space: pre-wrap;"><div><del style="font-weight: bold; text-decoration: none;">RO .................................. . . . . . . . . . . . . . . Was </del>admitted <del style="font-weight: bold; text-decoration: none;">to </del>this hospital on<del style="font-weight: bold; text-decoration: none;">..................................</del>.. and expired on ..<del style="font-weight: bold; text-decoration: none;">................................................................ </del>Doctor <del style="font-weight: bold; text-decoration: none;">....................................... (</del>Medical <del style="font-weight: bold; text-decoration: none;">Supdt</del>. Name of Hospital<del style="font-weight: bold; text-decoration: none;">)</del></div></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  ||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>See Reverse for Instructions <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>(To be <ins style="font-weight: bold; text-decoration: none;">attached </ins>and handed over to the relative of the <ins style="font-weight: bold; text-decoration: none;">deseased</ins>) <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">| </ins>Certified that Shri/Smt/<ins style="font-weight: bold; text-decoration: none;">Kum………………………………………………………S</ins>/W/D of <ins style="font-weight: bold; text-decoration: none;">……………………</ins>..<ins style="font-weight: bold; text-decoration: none;">…</ins>.<ins style="font-weight: bold; text-decoration: none;">…</ins>..<ins style="font-weight: bold; text-decoration: none;">R/O …………………………………………………………………was </ins>admitted <ins style="font-weight: bold; text-decoration: none;">dto </ins>this hospital on <ins style="font-weight: bold; text-decoration: none;">…………………………</ins>..and expired on <ins style="font-weight: bold; text-decoration: none;">……………………………………………………</ins>.. <ins style="font-weight: bold; text-decoration: none;">||  ||  ||  ||  ||  || </ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  ||  ||  || </ins>Doctor <ins style="font-weight: bold; text-decoration: none;">||  ||  || </ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|-</ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|  ||  ||  || </ins>Medical <ins style="font-weight: bold; text-decoration: none;">Supt </ins>. <ins style="font-weight: bold; text-decoration: none;">              </ins>Name of Hospital <ins style="font-weight: bold; text-decoration: none;">||  ||  || </ins></div></td></tr> <tr><td colspan="2" class="diff-side-deleted"></td><td class="diff-marker" data-marker="+"></td><td style="color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #a3d3ff; vertical-align: top; white-space: pre-wrap;"><div><ins style="font-weight: bold; text-decoration: none;">|}</ins></div></td></tr> <tr><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>{{create}}</div></td><td class="diff-marker"></td><td style="background-color: #f8f9fa; color: #202122; font-size: 88%; border-style: solid; border-width: 1px 1px 1px 4px; border-radius: 0.33em; border-color: #eaecf0; vertical-align: top; white-space: pre-wrap;"><div>{{create}}</div></td></tr> </table>

Ratheeshthankappan http://panchayatwiki.lsgkerala.gov.in/index.php?title=Panchayat:Repo18/vol2-page0405&diff=1874&oldid=prev 2018-01-05T06:09:37Z

<p>&#039;405 THE REGISTRATION OF BIRTH &amp; DEATH RULES, 1999 &#039;&#039;&#039; FORM - 4&#039;&#039;&#039; FORM No. 4 See Rule 7 MEDICAL CERTIFICATE OF CAUSE OF...&#039; താൾ സൃഷ്ടിച്ചിരിക്കുന്നു</p> <p><b>New page</b></p><div>405<br /> <br /> THE REGISTRATION OF BIRTH &amp; DEATH RULES, 1999 <br /> &#039;&#039;&#039;<br /> FORM - 4&#039;&#039;&#039; <br /> FORM No. 4 See Rule 7 MEDICAL CERTIFICATE OF CAUSE OF DEATH (Hospital in-patients. Not to be used for still births) To be sent to Registrar along with Form No. 2 (Death Report)<br /> Name of the Hospital............................................................................ I hereby certify that the person whose particulars are given below died in the hospital in<br /> Ward No. .................. On ....................... at .......................... A.M./P.M.<br /> Name of Deceased For use of<br /> Age at Death Statistical Office Sex If one year |If leSS than lf less than lf less than or more, age one year, one month, one day, in Years age in months age in Days age in Hours<br /> 1. Male 2. Female<br /> Interval betWeen on set &amp; death approx.<br /> Cause of Death<br /> I. Immediate Cause State the disease, injury or Complication which caused death, not the mode of dying such as heart failure, asthenia, etc. Antecedent cause Morbid conditions, if any, giving rise to the above cause, stating underlying conditions last.<br /> .....................................................<br /> (a)<br /> due to (or as a consequences of)<br /> (b) due to (or as a consequences of)<br /> II. Other significant conditions contributing to the death but not related to the disease or conditions causing it<br /> • • • • • • • • • • • • • • • • • • • • • • • • • •<br /> .................................<br /> Manner of Death (1) Natural (2) Accident (3) Suicide (5) Pending Investigation<br /> If deceased was a female, was pregnancy the death associated with?<br /> If Yes, was there a delivery? (1) Yes<br /> How did the injury occur?<br /> (4) Homicide<br /> (2) No<br /> (1) Yes (2) No<br /> Name and signature of the Medical Attendant certifying the cause of death<br /> Date of verification<br /> .........................................<br /> See Reverse for Instructions (To be detached and handed over to the relative of the deceased)<br /> Certified that Shri/Smt./Kum............................................<br /> S/W/D/ of Shri<br /> ....................................................<br /> RO .................................. . . . . . . . . . . . . . . Was admitted to this hospital on.................................... and expired on .................................................................. Doctor ....................................... (Medical Supdt. Name of Hospital)<br /> {{create}}</div>

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