Panchayat:Repo18/vol2-page0407

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)
| hereby 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 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 Female
2
Cause of death Interval between onset & death approx.
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)……………………………………………………………………………………………………………………
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

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