FORM NO. 4
(SEE RULE - 5)
Death Report
Registration Unit/Villages/Town /Municipality/Contonment/Taluk Tahsil/Block/Thana . . . . . . .
. . . . District.
1. Date Of death
2. Full name of the deceased
3. Name of the father/husband
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. Informant’s
I. Name
II. Address
Signature of the thumb mark
Of the informant.
Date:- - - - - - -
* Where the cause of death is medically certified , the caused marked ( ) in the Medical Certificate Form No.8 is to be entered here.
Note: - If the person is non-worker, insert the word “Nil” in the column for occupation
(SEE RULE - 5)
Death Report
Registration Unit/Villages/Town /Municipality/Contonment/Taluk Tahsil/Block/Thana . . . . . . .
. . . . District.
1. Date Of death
2. Full name of the deceased
3. Name of the father/husband
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. Informant’s
I. Name
II. Address
Signature of the thumb mark
Of the informant.
Date:- - - - - - -
* Where the cause of death is medically certified , the caused marked ( ) in the Medical Certificate Form No.8 is to be entered here.
Note: - If the person is non-worker, insert the word “Nil” in the column for occupation
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