REGISTRATION UNIT/VILLAGE/TOWN/MUNICIPALITY/CANTONMENT     TALIK/TEMSIL/BLOCK/THANA………………………………………………..

1. Date of Death:

     2.  Full name of the deceased:

     3.  Name of the father/husband/wife/ of the Deceased:

     4.  Place of Death:

     5.  Age:

     6.  Sex—Male/Female:

     7.  Marital Status:

     8.  Occupation:

     9.  Religion:

    10. Nationality:

    11. Permanent residential address:

    12. Cause of Death:

    13. Whether medically certified (Yes/No):

    14. Kind of medical attention received, if any:

    15. Information:

1. Name:
2. Address:

    Date..............................                                   Signature or Left thumb mark of the information.

      The address of the parents, incase of a child, husband/late husband in case of married/woman/widow/ and deceased if independent are to be given in this column.

Note 1. If the cause of death is not medically certified as certain the cause from the list of important cause of death.

         2. If the decease was over 1 year of age, give age in completed years, if the deceased was under 1 year of age give in completed months, and if below 1 month, give age in completed number of days and if below 1 day in hours.