FORM NO.8-A
(SEE RULE 8)
Medical Certificate of cause of Death
(For non-institutional death. No to be used for still births)
To be sent to Registrar along with form No.4 (Death Report)
I, hereby certify that the deceased Shri./Smt./Kum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Son of / Wife of / daughter of . . . . . . . . . . . . . . . . . . . . . . . . was under my treatment from. . . . . . to . . . . . . . . . and he / she died on . . . . . . . . at ... . . . . A.M./P.M.
Name of Deceased (Type of print)
Address of normal residence
For use by state office
Occupation
Date of birth
If under 1 year
If under 24 hours
Sex
Age in
Years
Last birth day
Date of birth
Marital
Status
S.M.W. or D
Religion
Month
Days
Hours
Minutes
I Interval between onset and death approx.
Immediate cause
State the disease, injury or complication (a)
Which caused death, not the mode of dying due to (or as consequences of) . . . . . . Det. List code incident cause (b).
Morbid conditions if any giving rise to the above causing, stating the - underlying condition last
(c) due to (or as a consequence of) N code.
II
Other significant conditions contributing to the death, but not related
To the disease or condition causing it.
Accident suicide, homicide (specify)
How did injury occur?
If deceased was a female:
Was the death associated with pregnancy
(Yes or No)
Was there a delivery
(Yes or No)
Name of
practitioner
(Rubber stamp) of institution or Medical Allopathic Ayurvedic- homeopathic – Yunani
Registration Sl. No. of Medical Practitioner/Attendant
Signature and address
Of medical attendant.
Date of report
See Reverse for instructions
Perforation (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 this hospital on
And expired on) Doctor:
(Medical Supdt. Name of Hospital)
(SEE RULE 8)
Medical Certificate of cause of Death
(For non-institutional death. No to be used for still births)
To be sent to Registrar along with form No.4 (Death Report)
I, hereby certify that the deceased Shri./Smt./Kum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Son of / Wife of / daughter of . . . . . . . . . . . . . . . . . . . . . . . . was under my treatment from. . . . . . to . . . . . . . . . and he / she died on . . . . . . . . at ... . . . . A.M./P.M.
Name of Deceased (Type of print)
Address of normal residence
For use by state office
Occupation
Date of birth
If under 1 year
If under 24 hours
Sex
Age in
Years
Last birth day
Date of birth
Marital
Status
S.M.W. or D
Religion
Month
Days
Hours
Minutes
I Interval between onset and death approx.
Immediate cause
State the disease, injury or complication (a)
Which caused death, not the mode of dying due to (or as consequences of) . . . . . . Det. List code incident cause (b).
Morbid conditions if any giving rise to the above causing, stating the - underlying condition last
(c) due to (or as a consequence of) N code.
II
Other significant conditions contributing to the death, but not related
To the disease or condition causing it.
Accident suicide, homicide (specify)
How did injury occur?
If deceased was a female:
Was the death associated with pregnancy
(Yes or No)
Was there a delivery
(Yes or No)
Name of
practitioner
(Rubber stamp) of institution or Medical Allopathic Ayurvedic- homeopathic – Yunani
Registration Sl. No. of Medical Practitioner/Attendant
Signature and address
Of medical attendant.
Date of report
See Reverse for instructions
Perforation (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 this hospital on
And expired on) Doctor:
(Medical Supdt. Name of Hospital)
కామెంట్లు లేవు:
కామెంట్ను పోస్ట్ చేయండి