Panchayat:Repo18/vol2-page0405: Difference between revisions
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<center>'''FORM - 4''' </center> | |||
''' | <center>[See Rule 7]</center><center> MEDICAL CERTIFICATE OF CAUSE OF DEATH </center><center>(Hospital in-patients. Not to be used for still births) </center><center>To be sent to Registrar along with Form No. 2 (Death Report)</center> | ||
FORM - 4''' | <center>Name of the Hospital............................................................................ </center><center>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.</center> | |||
Name of the Hospital............................................................................ I hereby certify that the person whose particulars are given below died in the hospital in | ---- | ||
Ward No. .................. | {| class="wikitable" | ||
Name of Deceased For use of | | Name of Deceased || || || || || || For use of Statistical office | ||
Age | |- | ||
1 | | || || Age of Death || || || || | ||
|- | |||
Cause of | | || Sex || In one year or more, age I years || If less than one year, age in month || If less than one month, age in days || If less than on day, age in hours || | ||
I. Immediate | |- | ||
| 1 || Male || || || || || | |||
|- | |||
due to (or as a consequences of) | | 2 || || || || || || | ||
|- | |||
II. Other significant conditions contributing to the death | | || Cause of death || || || || || | ||
|- | |||
| I. || Immediate cause.State the desease, injury or complication which caused death , not the mode of dying such as heart failure , asthenia etc. Atecedent cause || || || a)………………………………………………...due to ( or as a consequences of) || || | |||
Manner of | |- | ||
If | | || Morbid conditions , if any giving rise to the above cause, stataing underlying conditions last. || || || b)………………...……………………………..due to (or as a consequences of) || || | ||
If Yes, was there a delivery | |- | ||
| II. || Other significant conditions contributing to the death count not related to the disease or conditions causing it || || || c)…………………………………………………………………………………………………………………… || || | |||
|- | |||
(2) No | | || Manner of death How did injury occur? || || || || || | ||
|- | |||
Name and | | || 1) Natural 2)Accident 3) Suicide 4)Homicide 5)Pending investigation || || || || || | ||
Date of verification | |- | ||
| If deseased was a female, was pregnancy the death associated with? (1) Yes (2) No If Yes , was there a delivery (1) Yes (2) No || || || || || || | |||
See Reverse for Instructions (To be | |- | ||
Certified that Shri/Smt | | Name and sgnature of the Medical attendant clarifying the cause of death Date of verification....... || || || || || || | ||
|- | |||
..... | | || || || || || || | ||
|- | |||
| See Reverse for Instructions || || || || || || | |||
|- | |||
| (To be attached and handed over to the relative of the deseased) || || || || || || | |||
|- | |||
| Certified that Shri/Smt/Kum………………………………………………………S/W/D of ……………………..….…..R/O …………………………………………………………………was admitted dto this hospital on …………………………..and expired on …………………………………………………….. || || || || || || | |||
|- | |||
| || || || Doctor || || || | |||
|- | |||
| || || || Medical Supt . Name of Hospital || || || | |||
|} |
Latest revision as of 07:22, 24 January 2019
Ward No. .................. on ....................... at .......................... A.M./P.M.
Name of Deceased | For use of Statistical office | |||||
Age of Death | ||||||
Sex | In one year or more, age I years | If less than one year, age in month | If less than one month, age in days | If less than on day, age in hours | ||
1 | Male | |||||
2 | ||||||
Cause of death | ||||||
I. | Immediate cause.State the desease, injury or complication which caused death , not the mode of dying such as heart failure , asthenia etc. Atecedent cause | a)………………………………………………...due to ( or as a consequences of) | ||||
Morbid conditions , if any giving rise to the above cause, stataing underlying conditions last. | b)………………...……………………………..due to (or as a consequences of) | |||||
II. | Other significant conditions contributing to the death count not related to the disease or conditions causing it | c)…………………………………………………………………………………………………………………… | ||||
Manner of death How did injury occur? | ||||||
1) Natural 2)Accident 3) Suicide 4)Homicide 5)Pending investigation | ||||||
If deseased was a female, was pregnancy the death associated with? (1) Yes (2) No If Yes , was there a delivery (1) Yes (2) No | ||||||
Name and sgnature of the Medical attendant clarifying the cause of death Date of verification....... | ||||||
See Reverse for Instructions | ||||||
(To be attached and handed over to the relative of the deseased) | ||||||
Certified that Shri/Smt/Kum………………………………………………………S/W/D of ……………………..….…..R/O …………………………………………………………………was admitted dto this hospital on …………………………..and expired on …………………………………………………….. | ||||||
Doctor | ||||||
Medical Supt . Name of Hospital |