Panchayat:Repo18/vol2-page0403

FORM - 2
[see Rule No 5]
DEATH REPORT FORM
Death Report Legal Information This part to be added to the

Death Register

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)
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 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:
2. Counter signature and seal of the authorities concerned (in the case of hospitals/institutions) (After completing all columns 1 to 17 informant will put date and signature here:) Date
Signature or left thumb mark of the informant

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:
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 (write name of the religion)
9. Occupation of the deceased: (If no occupation write 'Nil')
10. Type of the Medical attention received before death (Tick the appropriate entry below)

To be filled by the informant

1. Institutional
2. Medical attention other than institution
3. No medical attention 11. Was the cause of death medically certified? (Tick the appropriate entry below) 1. Yes 2. No
12. Name of Disease or Actual Cause of Death: (For all deaths irrespective of whether medically certified or not)
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 2. No
14. If used to habitually smoke for how many years?
15. If used to habitually chew tobacco in any 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)

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