Panchayat:Repo18/vol2-page0407

THE REGISTRATION OF BIRTH & DEATH RULES 1999

                                                                          FORM - 4A

Operation-State the Condition for which the operation was performed. Dysentry-Specify whether bacillary, amoebic, etc., if known. Complications of pregnancy or delivery-Describe the complication specifically. Tuberculosis - Give organs affected. Symptomatic statement.- Convulsions, diarrhoea, fever, ascites, jaundice, debility etc., are symptoms which may be due to any one of a number of different conditions. Sometimes nothing more is known, but whenever possible, give the disease which caused the symptom. Manner of Death-Deaths not due to external cause should be identified as 'Natural'. If the cause of death is known, but it is not known whether it was the result of an accident, suicide or homicide and is subject to further investigation, the cause of death should invariably be filled in and the manner of death should be shown as 'Pending investigation'.

FORM No. 4A (See Rule 7) MEDICAL CERTIFICATE OF CAUSE OF DEATH (For non-institutional deaths. Not to be used for still births) To be sent to Registrar along with Form No. 2 (Death Report) | heraby certify that the deceased Shri/Smt./Kum............................... Son of/wife of/daughter of ............................................ resident of ............................. was under my treatment from - - - - - - - - - - - - - - - to ................. and he/she died on ..................... at ...................... A.M./P.M. Name of the Deceased For use of Statistical Office Age at Death Sex Age in If less than 1 if less than one if less than Completed year age in month age in one day age Years Months Days in Hours 1. Male

2. Female Cause of Death Interval between onset & death approx. I. Immediate Cause (a) .. l ..-------------- ............. I State the disease, injury or complication due to (or as which caused death, not the mode of a consequ- dying such as heart failure, asthenia, etc. ences of) Antecedent cause (b) ............ ............. . . . . . . . . . . . . . . ... ... ************** ון Morbid conditions, if any, giving rise due to (or as to the above Cause, stating under- a COոSequ- | wind Conditions last ΘΠ f yIng ons las ences of) (c)............. ............... ··············· lll. Other significant conditions contributing .................. || || ............... . . . . . . . . . . . . . . . . to the death but not related to the disease or Conditions causing it. ................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . lf deceased 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 signature of the Medical Practitioner, Certifying the cause of death Date of Certification ......................................................................... - . . . . See Reverse for instructions