Form No. 8
Satistical information
This part to be detached and sent for satistical processing
   To be filled by the informant
8. Town or Village of Residence of the deceased :
(Place where the deceased actually lived. This
can be different from the place where the death
occurred. The house address is not required to be
  a) Name of Town/Village :
  b) Is it a Town or village : (Tick the appropriate entry below)
  1)    Town                  2.    Village
  c) Name of District :
  d) Name of State :
9. Religion : (Tick the appropriate entry below)
  1. Hindu         2. Muslim         3. Christian
  4. Any other religion : (Write the name of the religion)
10. Occupation of the deceased :
(If no occupation write'Nil')
11. Type of medical attention received before death :
(Tick the approprieate entry below)
  1. Institutional
  2. Medical attention other than institution
  3. No medical attention
   To be filled by the informant
12. Was the cause of death medically certified?
(Tick the appropriate entry below) :
                  1. Yes                2. No
13. Name of disease or Actual Cause of Death :
(For all deaths irrespective of whether medically
certified or not)
14. In case this is a female death, did the death occur
while pregnant, at the time of delivery or within
6 weeks after the end of pregnancy :
(Tick the appropriate entry below)
                   1. Yes               2. No
15. If to habitually smoke -
for how many years?
16. If used to habitually chew tobacco in any form :
 for how many years?

If used to habitually chew arecanut in any form
 (Including pan masala) - for how many years ?

18. If used to habitually drink alcohol : for how many
(Columns to filled are over. Now put signature at left)

To be filled by the Registrar
Name : Code No.
District :
Tehsil :
Town / Village :
Registration Unit :
Registration No.:   Registration Date:
Date of Birth:
Sex:             1. Male   2. Female
Age : Years/months/days/hours
Place of Birth : 1. Hospital/Institution          2. House

Name and Signature of the Registrar

Click here for Medical Certificate of Cause of Death (Form No. 4)


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