Panchayat:Repo18/vol2-page0405

FORM - 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)

Name of the Hospital............................................................................ I hereby certify that the person whose particulars are given below died in the hospital in Ward No. .................. On ....................... at .......................... A.M./P.M. Name of Deceased For use of 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 1. Male 2. Female Interval betWeen on set & death approx. Cause of Death 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. ..................................................... (a) due to (or as a consequences of) (b) due to (or as a consequences of) II. Other significant conditions contributing to the death but not related to the disease or conditions causing it • • • • • • • • • • • • • • • • • • • • • • • • • • ................................. Manner of Death (1) Natural (2) Accident (3) Suicide (5) Pending Investigation If deceased was a female, was pregnancy the death associated with? If Yes, was there a delivery? (1) Yes How did the injury occur? (4) Homicide (2) No (1) Yes (2) No Name and signature of the Medical Attendant certifying the cause of death Date of verification ......................................... See Reverse for Instructions (To be detached and handed over to the relative of the deceased) Certified that Shri/Smt./Kum............................................ S/W/D/ of Shri .................................................... RO .................................. . . . . . . . . . . . . . . Was admitted to this hospital on.................................... and expired on .................................................................. Doctor ....................................... (Medical Supdt. Name of Hospital)