1. |
Date of Birth : (Enter the exact day, .....................................................................................
month and year the death took place (e.g. 1-1-2000) |
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2. |
Name of the deceased : ....................................................................................................
(Full name as usually written) |
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3. |
Sex of the deceased : .......................................................................................................
(Enter "Male or female",do not use abbreviation) |
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4. |
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 in completed number of days, and if below
one day, in hours.) |
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5. |
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) |
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1. Hospital/Institution Name : ............................................................................................ |
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2. House Address : ............................................................................................................ |
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3. Other place : ................................
................................................................................ |
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6. |
Name of the father/husband : ........................................................................................... |
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7. |
Informant's name : ...........................................................................................................
Address : ...........................................................................................................................
(After completing all columns 1 to 17, informant will put date and
signature here:) |
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Date: Signature
or left thumb mark of the informant |