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Death - Application - Form

This document is an application form for a death certificate. It requests information such as the deceased's name, date and place of death, sex, permanent address, as well as the applicant's name and address. The form notes that it is being submitted under the Registration of Birth and Death Act of 1969 and the Odisha Births and Deaths Registration Rules of 2001 to obtain a death certificate.

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AJCBP 2018-21 CIVIL ENGINEERING
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177 views

Death - Application - Form

This document is an application form for a death certificate. It requests information such as the deceased's name, date and place of death, sex, permanent address, as well as the applicant's name and address. The form notes that it is being submitted under the Registration of Birth and Death Act of 1969 and the Odisha Births and Deaths Registration Rules of 2001 to obtain a death certificate.

Uploaded by

AJCBP 2018-21 CIVIL ENGINEERING
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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APPLICATION FORM FOR DEATH CERTIFICATE

To,
The Registrar of Births & Deaths &
Executive Offi cer,, N.A.C.,Patna garh.

Sub:- Issue of Death certificate u/s-l7of the Registration of Birth & Death
Act.1969 read with Odisha Births & Deaths Registration Rule_2001.

Sir/Madam,
r am submitting herewith the following particulars for issue of Death
certificate u/s-17of the Registration of Birth & Death Act.l969 read with odisha
Births & Deaths Registration Rule-2001.
(To be filled in Block Letters)
1. Name of the deceased (In full):
2. Name of Fatrher/Husband : ............,........
4. Place of Death :

5. Date of Death , Ifl Efl


6. Sex : Male l--l Female f----l
7. Permanent Address of Deceased -Village...

8. Name &Address of theApplicant-Name.

I.D. Proof No (Any)


9. Contact Number

Ful1 signature of the Applicant


(Father/Mother / Guardian)

FOR OFFICE USE ONLY

Challan /Receipt No.................................Date

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