Panchayat:Repo18/vol2-page0403: Difference between revisions
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==== ''FORM - 2''' ==== | ==== ''FORM - 2''' ==== | ||
{| class="wikitable" | {| class="wikitable" | ||
|- | |- | ||
! | ! !! 'FORM - 2 [see Rule No5] !! | ||
|- | |- | ||
| Death Report Legal Information This part to be added to the | | Death Report Legal Information This part to be added to the | ||
Line 16: | Line 11: | ||
Statistical Information This part to be detached and sent for | Statistical Information This part to be detached and sent for | ||
statistical processing | statistical processing | ||
|| | || | ||
|- | |- | ||
| To be filled by the informant 1. | | To be filled by the informant 1. | ||
Date of Death: (Enter the exact day, month and year the death took place e.g.1-1-2000) Name of the deceased: (Full name as usually written) (a) Permanent address of the deceased: (b) Name of the father/husband: *[(C) Name of mother (d) Address of the deceased at the time | Date of Death: (Enter the exact day, month and year the death took place e.g.1-1-2000) <br> | ||
of the death.] Sex of the deceased: (Enter 'Male' or “Female': do not use abbreviation) Age of the deceased (If the deceased was over 1 year of age, give age in completed years. If the deceased was below 1 year of age, give age in months, and if below 1 month give age in completed number of days, and if below one day, in hours.) Place of death: (Tick the appropriate entry 1, 2 or 3 below and give the name of the Hospital/ Institution or the address of the house where the death took-place). If other place, give location 1. Hospital institution Name: 2. House: Address: 3. Other Place: Informant's name: 1. Address: | Name of the deceased: (Full name as usually written) <br> | ||
(a) Permanent address of the deceased: <br> | |||
(b) Name of the father/husband: *[(C) Name of mother <br> | |||
(d) Address of the deceased at the time | |||
of the death.] Sex of the deceased: (Enter 'Male' or “Female': do not use abbreviation) Age of the deceased (If the deceased was over 1 year of age, give age in completed years. If the deceased was below 1 year of age, give age in months, and if below 1 month give age in completed number of days, and if below one day, in hours.) <br> | |||
Place of death: (Tick the appropriate entry 1, 2 or 3 below and give the name of the Hospital/ Institution or the address of the house where the death took-place). If other place, give location <br> | |||
1. Hospital institution Name: <br> | |||
2. House: Address: 3. Other Place: <br> | |||
Informant's name: <br> | |||
1. Address:<br> | |||
2. Counter signature and seal of the | |||
authorities concerned (in the case of | authorities concerned (in the case of | ||
hospitals/institutions) (After completing all columns 1 to 17 | hospitals/institutions) (After completing all columns 1 to 17 informant will put date and signature here:) Date <br> | ||
mark of the informant 7. Town or Village of Residence of the | Signature or left thumb mark of the informant <br> | ||
|| To be filled by the informant <br> | |||
7. Town or Village of Residence of the | |||
deceased: (Place where the deceased actually lived. This can be different from the place where the death occured. The house address is not required to be entered.) (a) Name of Town/Village: (b) Is it a town of village: (Tick the appro priate entry below) | deceased: (Place where the deceased actually lived. This can be different from the place where the death occured. The house address is not required to be entered.) (a) Name of Town/Village: (b) Is it a town of village: (Tick the appro priate entry below) | ||
1. Town: 2. Village: (C) Name of District: (d) Name of State: Religion (Tick the appropriate entry below 1. Hindu 2. Muslim 3. Christian 4. Any other religion | 1. Town: <br> | ||
(write name of the religion) 9. Occupation of the deceased: | 2. Village: <br> | ||
(If no occupation write 'Nil') 10. Type of the Medical attention received | (C) Name of District: (<br> | ||
d) Name of State: <br> | |||
Religion <br> | |||
(Tick the appropriate entry below 1. Hindu 2. Muslim 3. Christian 4. Any other religion | |||
(write name of the religion) <br> | |||
9. Occupation of the deceased: | |||
(If no occupation write 'Nil') <br> | |||
10. Type of the Medical attention received | |||
before death (Tick the appropriate entry below) | before death (Tick the appropriate entry below) | ||
|| To be filled by the informant 1. Institutional 2. Medical attention other than institution | || To be filled by the informant <br> | ||
1. Institutional <br> | |||
2. Medical attention other than institution<br> | |||
3. No medical attention 11. Was the cause of death medically | 3. No medical attention 11. Was the cause of death medically | ||
certified? (Tick the appropriate entry below) 1. Yes | certified? (Tick the appropriate entry below) 1. Yes | ||
2. No 12. Name of Disease or Actual Cause of | 2. No <br> | ||
12. Name of Disease or Actual Cause of | |||
Death: (For all deaths irrespective of | Death: (For all deaths irrespective of | ||
whether medically certified or not) 13. In case this is a female death, did the | whether medically certified or not) <br> | ||
13. In case this is a female death, did the | |||
Death occur while pregnant, at the time of delivery or within 6 weeks after the end of pregnancy (Tick the appropriate entry below) 1. Yes | Death occur while pregnant, at the time of delivery or within 6 weeks after the end of pregnancy (Tick the appropriate entry below) 1. Yes | ||
2. No 14. If used to habitually smoke for how many | 2. No <br> | ||
years? 15. If used to habitually chew tobacco in any | 14. If used to habitually smoke for how many | ||
form - for how many years? 16. If used to habitually chew arecanut in any form (including pan masala) - for how many years? 17. If used habitually drink alcohol - for how many years? (Columns to be filled are over, Now put signature at left) | years? <br> | ||
15. If used to habitually chew tobacco in any | |||
form - for how many years? <br> | |||
16. If used to habitually chew arecanut in any form (including pan masala) - for how many years? <br> | |||
17. If used habitually drink alcohol - for how many years? (Columns to be filled are over, Now put signature at left) | |||
|- | |- |
Revision as of 07:17, 2 February 2018
FORM - 2'
'FORM - 2 [see Rule No5] | ||
---|---|---|
Death Report Legal Information This part to be added to the
Death Register |
DEATH REPORT FORM
Death Report Statistical Information This part to be detached and sent for statistical processing |
|
To be filled by the informant 1.
Date of Death: (Enter the exact day, month and year the death took place e.g.1-1-2000) |
To be filled by the informant 7. Town or Village of Residence of the
deceased: (Place where the deceased actually lived. This can be different from the place where the death occured. The house address is not required to be entered.) (a) Name of Town/Village: (b) Is it a town of village: (Tick the appro priate entry below)
1. Town: |
To be filled by the informant 1. Institutional |
To be filled by the Registrar Registration No: Registration Date: Registration Unit: Town/Village
District: Remarks: (if any) Name and Signature of the Registrar |
To be filled by the Registrar Name
Code No. District: Tahsil: Town/Village: Registration Unit: Registration No.: Registration Date: |
To be filled by the Registrar Date of Death: Sex: 1. Male
2. Female Age: Years/Months/Days/Hours Place of Birth: 1. Hospital/Institution 2. House 3. Other Place Name and Signature of the Registrar |
ഈ താൾ 2018 -ലെ പഞ്ചായത്ത് റെപ്പോ നിർമ്മാണം യജ്ഞത്തിന്റെ ഭാഗമായി സൃഷ്ടിച്ചതാണ്. |