APPLICATION FORM FOR DEATH CERTIFICATE
To
The Registrar of Births & Deaths, Municipality, Koraput.
Sub:
Issue of Death Certificate
Sir/Madam,
I am submitting here with the following particulars for issue of Death Certificate under section-17.
(....................................Copy/ Copies)
(For Office use only)
Registration No.______________________ Date of Registration : ___________ / ____________ / _______________
Application No.____________________________ Search Fee
No. of year ______________________
Challan Amount: Rs.______________ Challan No: _____________________ Challan Date. :_________________
M / R Amount : Rs.________________ M/R No : ______________________ _M/R Date:_____________________
Issue No. :____________ Issue Date _____________ ID No.______________________ID Type :________________
Ortps Ack. No.___________________________________
Date: ___________ / ____________ / ______________
(FILL THE BLANKS USING CAPITAL LETTERS)
Date of Death*________________________ (DD/MM/YYYY)
Deceased Name : ____________________________
(
Care of*
_______________________
First Name)
Father
Gender_______________ (Male/Female)
(Middle Name)
________________________
(Last/Surname)
Husband
Father/ Husband Name* ____________________________
____________________ _____________________
(First Name)
(Middle Name)
(Last/Surname)
Deceased Age (In Years)*_________Age (In Months)_________Age (In Days)__________Age (In Hours)________
PERMANANT ADDRESS
Address Line At*_____________________________Po :___________________ Police Station:_________________
Country*_________________ State*_______________________ District*__________________________________
Pin :________________ Mobile No :______________________ email ID :___________________________________
PLACE OF DEATH
House
Hospital
Place of Death*______________________________________________________
Address Line*At:____________________________Po :_____________________ Police Station:________________
Country*_________________ State*________________________ District*_________________________________
Pin :______________________
INFORMANT / APPLICANT NAME AND ADDRESS:
Name*__________________________________Sex :_________(M/F)
Same as Permanent Address
Others
Father / Husband Name*__________________________________________________________________________
Address Line*At:_____________________________Po: _____________________ Police Station________________
Country*_________________ State*_________________________ District*________________________________
Pin :____________________ Relation with the Deceased*________________________________________________
Identity Proof Submitted*_________________________________(PAN CARD/PASSPORT/DRIVING LICENC / RATION CARD/
VOTER ID CARD / PHOTO ID CARD issued by POST OFFICE/
GOVT / DEFENCE ID CARD)
TOWN OR VILLAGE OF RESIDENCE OF DECEASED :
Is it a Town or Village*_____________________ Name of Town/ Village*__________________________________
Country*_____________________ State*_________________________ District*____________________________
OTHER DETAILS :
Religion of the Deceased*____________________
Deceased Occupation*_____________________________
Type of medical attention received before death :_______________________________________________________
(INSTITUTIONAL/ MEDICAL ATTENTION OTHER THAN INSTITUTIONAL / NO MEDICAL ATTENTION)
Is Death Medically Certified*(Yes/No):______________ Cause of Death*__________________________________
Pregnancy Death :_________________
Smoking (Yes / No):___________________
Smoking Duration (In Years):____________________
Chewing Tobacco (Yes / No):___________
Chewing Tobacco Duration (In Years):____________
Chewing Arcenut (Yes / No):___________
Chewing Arcenut Duration (In Years):____________
Drink Alcohol (Yes / No):______________
Drink Alcohol Duration ( In Years):_______________
Proof of Events*______________________________ (Discharge Certificate / Authorisation Letter)
Miss Case*__________________ (Yes/No) Memo No.:____________________ Order No. :__________________
Full Signature of Informant / Applicant*
Time:
Date*:
Place*:
Signature of Registrar
Municipality Koraput