Form No.4
(See Rule7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(Hospital in-patients. Not to be used for still births)
To be sent to Registrar along with Form No.2 (Death Report)
 
Name of the Hospital ...................................................................................................................

            I hereby certify that the person whose particulars are given below died in the hospital in Ward
No.................................. on ......................... at ...................... A.M./P.M.
 
NAME OF DECEASED
For use of Statistical Office
Sex Age of Death
If 1 year or more,
age in years
If less then 1 year,
age in months
If less than one
month, age in days
If less than one
day, age in hours
 
  1. Male
  2. Female
 
 
 
 
 
CAUSE OF DEATH
       
       
  I
Immediate cause
State the disease, injury or complication
Which caused death, not the mode of
dying such as heart failure, asthenia, etc.
(a)
____________
due to (or as a
consequences of)
 
 Antecedent cause
Morbid conditions, if any, giving rise to the
(b)
____________
due to (or as a
consequences of)
  above cause, stating underlying
conditions last
 
     (c) __________
       
 
II Other significent conditions contributing to   ____________
  the death but not related to the disease    
  or conditions causing   _______________
Interval between
on set & death
approx.
 
 
________
 
 
 
________
 
 
 
________
 
 
 
________
 
________
 
 
 
 
________
 
 
 
________
 
 
 
________
 
 
 
________
 
________
 
  Manner of Death How did the injury occur?
 
1.Natural          2.Accident       3.Suicide             4.Homicide
5.Pending investigation

If deceased 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 Signature of the Midical Attendant Certifying the cause of death
Date of Verification ____________________________________________

SEE REVERSE FOR INSTRUCTIONS

(To be detached and handed over to the relative of the deceased)

Certified that Shri/Smt./Kum ________________S/W/D of Shri ______________
R/o_____________________________________ was admitted to his hospital on _______________________
and expired on ___________________________
 
Doctor___________
(Medical Supdt.        
(Name of Hospital)    
 
 
Click here for Medical Certificate of Cause of Death (Form No. 4A)
 
 
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