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 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