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THE REGISTRATION OF BIRTH & DEATH RULES, 1999 FORM - 4 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) 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 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 |
|
ഈ താൾ 2018 -ലെ പഞ്ചായത്ത് റെപ്പോ നിർമ്മാണം യജ്ഞത്തിന്റെ ഭാഗമായി സൃഷ്ടിച്ചതാണ്. |