Certified that Shri/Smt./Kum ......... S/W/D of Shri.................. RO ................... was
under my treatment from ..................... to ........................... and he/she expired on ............ at
- - - - - - - - - - - - A.M./P.M.
Medical attendant with Registration No
Name of deceased.- To be given in full. Do not use initials. If deceased is an infant, not yet named at time of death, write. 'Son of (S/o) or 'Daughter of (D/o)', followed by names of mother and father.
Age.- 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.
Cause of Death.- This part of the form should always be completed by the attending physician personally. ,br> The certificate of cause of death is divided into two parts, and II. Part I is again divided into three parts, lines (a) (b) (c). If a single morbid condition completely explains the deaths, then this will be written on line (a) of Part I, and nothing more need be written in the rest of Part I or in Part l, for example, Smallpox, lobar pneumonia, cardiac beriberi, are sufficient cause of death and usually nothing more is needed.
Often, however, a number of morbid conditions will have been present at death, and the doctor must then Complete the certificate in the proper manner so that the correct underlying cause will be tabulated. First enter in Part (a) the immediate cause of death. This does not mean the mode of dying, e.g., heart failure, respiratory failure, etc. These terms should not appear on the Certificate at all since they are modes of dying and not causes of death. Next consider whether the immediate cause is a complication or delayed result of some other cause. If so, enter the antecedent cause in Part I, line (b). Sometimes there will be three stages in the course of events leading to death. If So, line (c) will be completed. The underlying cause to be tabulated is always written last in Part I.
Morbid Conditions or injuries may be present which were not directly related to the train of events causing death but which Contributed in some way to the fatal outcome. Sometimes the doctor finds it difficult to decide, especially for infant deaths, which of several independent conditions was the primary cause of death; but only one cause can be tabulated, so the doctor must decide. if the other diseases are not effects of the underlying cause, they are entered in Part II.
Do not write two or more conditions on a single line. Please Write the names of the diseases (in full) in the certificates as legibly as possible to avoid the risk of their being misread.
Onset- Complete the column for interval between onset and death whenever possible, even if very approximately, e.g., "from birth" "several years."
Accidental or violent deaths.- Both the external cause and the nature of the injury are needed and should be stated. The doctor or hospital should always be able to describe the injury, stating the part of the body injured, and should give the external cause in full when this is shown. Example: (a) hypostatic pneumonia; (b) Fracture of neck of femur, (c) Fall from ladder at home.
Maternal deaths.- Be sure to answer the questions on pregnancy and delivery. This information is needed for all Women of child-bearing age, even though the pregnancy may have had nothing to do with the death. :
Old age or senility- Old age (or senility) should be not given as a cause of death if a more specific cause is known. If old age was a contributory factor, it should be entered in Part II. Example: (a) Chronic bronchitis, Il old age.