Form No.4A
(See Rule7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(for Non-institutional deaths. Not to be used for still births)
To be sent to Rgistrar along with Form No.2 (Death Report)
 
 
I herby certify that the deceased Shri/Smt.Kum________________________________Son of/
wife of/daughter of________________________resident of________________________________
____________________________was under my treatment from_______________to _______________
and he/she died 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.
 
 
________
 
 
 
________
 
 
 
________
 
 
 
________
 
________
 
 
 
 
________
 
 
 
________
 
 
 
________
 
 
 
________
 
________
 
Name and Signature of the Midical Practitioner Certifying the cause of death
Date of Certification _____________________________________________
 

 
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 under my treatment
from_____________to__________________and he/she expired on___________________________
at____________________________________A.M./P.M.
 

Doctor _______________________________
Signature and address of Medical Practitioner/
Medical Attendant with Registration No.         
 
Click here for Directions for completing the form of Medical Certificate of cause of death