FORM NO.

2 DEATH REPORT DEATH REPORT

FORM NO.2
Legal information Statistical information

This part to be added to the Death Register This part to be detached and sent for statistical processing

To be filled by the informant To be filled by the informant To be filled by the informant

11. 15.
1. Date of Death : (Enter the exact day, month and Town or Village of Residence of the deceased: (Place where the deceased Was the cause of death medically certified?: (Tick the
year the death took place e.g. 1-1-2000) actually lived. This can be different from the place where the death occurred. The appropriate entry below)
house address is not required to be entered.)
2. Name of the Deceased : 1.Yes 2. No
(Full name as usually written) a) Name of Town/Village :
16.
UID No of deceased (if any) b) Is it a town or village :(Tick the appropriate entry below) Name of Disease or Actual Cause of Death : (For all deaths
1. Town 2. Village irrespective of whether medically certified or not)
3. Sex of the deceased : : (Enter “Male, or “ Female” or “Transgender”) c) Name of District :
do not use abbreviation)
4. Name of Mother: d) Name of State : 17.
UID No of Mother (if any) In case this is a female death, did the death occur while
12. pregnant, at the time of delivery or within 6 weeks after the
5. Religion : (Tick the appropriate entry below) end of pregnancy: (Tick the appropriate entry below)
Name of Father
UID No of Father(if any)
1. Hindu 2. Muslim 3.Christian 1.Yes 2. No
5a Name of husband/wife 4. Any other religion: (write the name of the religion)
UID No of husband/wife (if any) 18. If used to habitually smoke -
for how many years?
5b Age of husband/wife:

DEATH REPORT FORM

13. Occupation of the deceased:
5c

To be detached and sent statistical processing

Contact details of husband/wife: (If no occupation write ‘Nil’) 19. If used to habitually chew tobacco in any
form -
6. Age of the deceased: (if the deceased was over 1 year of age, give

FORM No 2
for how many years?

(See Rule 5)
age in completed years. If the deceased was below 1 year of age, give 14. Type of medical attention received before death: (Tick the appropriate entry
age in months, and if below 1 month give age in completed number of below)
days, and if below one day, in hours) 20. If used to habitually chew arecanut in any form
1. Institutional (including pan masala) -
7. Address of the deceased at the for how many years?
time of death:
2. Medical attention other than institution
8. Permanent address of the deceased:
9. Place of death: (Tick the appropriate entry 1, 2 or 3 below and give the name of the 21. If used to habitually drink alcohol -
3. No medical attention
Hospital/ Institution or the address of the house where the death took place. If other for how many years?
place, give location)

1.Hospital/ Name :
Institution
2.House Address :
3.Other Place

10. Informant’s name :

UID No of Informant (if any)

Address :

(After completing all columns

1 to 21, informant will put date
and signature here:)
Declaration :
To the best of my knowledge and information, the detail of Aadhaar of deceased is not
available.
Date : Signature or left thumb mark of the informant (Columns to be filled are over. Now put signature at left)

To be filled by the Registrar To be filled by the Registrar

Registration No. : Registration Date : Name Code No. Registration No. : Registration Date :
Registration Unit : District : Date of Death : Sex : 1.Male 2.Female
Town/Village : District : Tahsil : Age : Years/months/days/hours
Remarks : (if any) Town/Village : Place of Death : 1.Hospital/Institution 2.House 3. Other Place
Registration Unit :
Name and Signature of the Registrar Name and Signature of the Registrar
 FORM No. 8
(See Rule 12)

DEATH REGISTER

Legal information
This part to be added to the Death Register
To be filled by the informant

1. Date of Death : (Enter the exact day, month

and year the death took place e.g. 1-1-2000)
Name of the Deceased :
(Full name as usually written)
2.
UID No of deceased (if any)

3. Sex of the deceased : (Enter “male” , “female” , Transgender)

do not use abbreviation
Name of Mother:
4. UID No of Mother (if any)

Name of Father
5. UID No of Father(if any)

Name of husband/wife
5a UID No of husband/wife (if any)
5b Age of husband/wife:

5c Contact details of husband/wife:

6 Age of the deceased: (if the deceased was over 1 year of age,
give age in completed years. If the deceased was below 1 year
of age, give age in months, and if below 1 month give age in
completed number of days, and if below one day, in hours)
7.
Address of the deceased at the time of death:
8. Permanent address of the deceased:
9. Place of death: (Tick the appropriate entry 1, 2 or 3 below and give the
name of the Hospital/ Institution or the address of the house where the
death took place. If other place, give location)

1.Hospital/ Name :
Institution
2.House Address :
3.Other Place
10. Informant’s name :
UID No of Informant (if any)

Address :

(After completing all

columns 1 to 21, informant
will put date and signature
here:)
Declaration :

To the best of my knowledge and information, the detail of Aadhaar of deceased is not
available.

Date : Signature or left thumb mark of the informant

To be filled by the Registrar

Registration No. : Registration Date :
Registration Unit :
Town/Village : District :
Remarks : (if any)

Name and Signature of the Registrar

 FORM NO. 4
(See Rule 7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(Hospital In-patients. Not to be used for still births)
To be sent to Registrar along with Form No. 2 (Death Report)

Name of the Hospital ……………………………………………………………….

I hereby certify that the person whose particulars are given below died in the hospital in Ward No…………………….. on ……..…………………….. at ………AM/PM

NAME OF DECEASED For use of Statistical Office

Sex Age at Death
If 1 year or more, If less than 1 year, age If less than one month, If less than one day, age
age in years in month age in days in hours
1. Male
2. Female

CAUSE OF DEATH Interval between onset

and death approx.
I (a) ……………………………………..
Immediate cause due to (or as a consequences of)
State the disease, injury or complication which
caused death, not the mode of dying such as heart
failure, asthenia, etc.

Antecedent cause (b) ……………………………………..

due to (or as a consequences of)
Morbid conditions, if any, giving rise to the above
cause, stating underlying conditions last

(c) ……………………………………..
II
Other significant conditions contributing to the death ….……………………………………..
but not related to the disease or condition causing it
….……………………………………..

Manner of Death How did the injury occur?

1. Natural 2. Accident 3. Suicide 4. Homicide

5. Pending investigation

If deceased was a female, was pregnancy the death associated with? 1. Yes 2. No
If yes, was there a delivery? 1. Yes 2. No

Name and signature of the Medical Attendant certifying the cause of death

Date of verification ……………………………………………………………….

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 admitted to this hospital on ………………………………….

and expired on …………………………………………..

Doctor ……………………………………………………..
(Medical Supdt.
Name of Hospital)
 MEDICAL CERTIFICATE OF CAUSE OF DEATH
Directions for completing the form

Name of deceased : To be given in full. Do not use initials. If deceased is an infant, not yet named at time of death, write ‘Son of
(S/o)’ or ‘Daughter of (D/o)’, followed by names of mother and father.

Age : If the deceased was over 1 year of age, give age in completed years. If the deceased was below 1 year of age, give age in
months and if below 1 month give age in completed number of days, and if below one day, in hours.

Cause of Death : This part of the form should always be completed by the attending physician personally.

The certificate of cause of death is divided into two parts, I and II. Part I is again divided into three parts, lines (a) (b)
(c). If a single morbid condition completely explains the deaths, then this will be written on line (a) of Part I, and nothing more
need be written in the rest of Part I or in Part II, for example, smallpox, lobar pneumonia, cardiac beriberi, are sufficient cause of
death and usually nothing more is needed.

Often, however, a number of morbid conditions will have been present at death, and the doctor must then complete
the certificate in the proper manner so that the correct underlying cause will be tabulated. First, enter in Part I(a) the immediate
cause of death. This does not mean the mode of dying, e.g., heart failure, respiratory failure, etc. These terms should not be
appear on the certificate at all since they are modes of dying and not causes of death. Next consider whether the immediate cause
is a complication or delayed result of some other cause. If so, enter the antecedent cause in Part I, line (b). Sometimes there will
be three stages in the course of events leading to death. If so, line (c) will be completed. The underlying cause to be tabulated is
always written in last in Part I.

Morbid conditions or injuries may be present which were not directly related to the train of events causing death but
which contributed in some way to the fatal outcome. Sometimes the doctor finds it difficult to decide, especially for infant
deaths, which of several independent conditions was the primary cause of death; but only one cause can be tabulated, so the
doctor must decide. If the other diseases are not effects of the underlying cause, they are entered in Part II.

Do not write two or more conditions on a single line. Please write the names of the diseases (in full) in the certificates
as legibly as possible to avoid the risk of their being misread.

Onset : Complete the column for interval between onset and death whenever possible, even if very approximately, e.g., “from
birth” “several years”.

Accidental or violent deaths : Both the external cause and the nature of the injury are needed and should be stated. The doctor or
hospital should always be able to describe the injury, stating the part of the body injured, and should give the external cause in
full when this is shown. Example : (a) Hypostatic pneumonia; (b) Fracture of neck of femur; (c) Fall from ladder at home.

Maternal deaths : Be sure to answer the question on pregnancy and delivery. This information is needed for all women of child-
bearing age, even though the pregnancy may have had nothing to do with the death.

Old age or senility : Old age (or senility) should not be given as a cause of death if a more specific cause is known. If old age was
a contributory factor, it should be entered in Part II. Example : (a) Chronic bronchitis, II old age.

Completeness of information : A complete case history is not wanted, but, if the information is available, enough details should
be given to enable the underlying cause to be properly classified.

Example : Anaemia – Give type of anaemia, if known. Neoplasm – Indicate whether benign or malignant, and site, with site of
primary neoplasm, whenever possible, Heart disease – Describe the condition specifically; if congestive heart failure, chronic on
pulmonale, etc., are mentioned, give the antecedent conditions. Tetanus – Describe the antecedent injury, if known. Operation –
State the condition for which the operation was performed. Dysentery – Specify whether bacillary, amoebic, etc., if known.
Complications of pregnancy or delivery – Describe the complication specifically, Tuberculosis – Give organs affected.

Symptomatic statement : Convulsions, diarrhea, fever, ascites, jaundice, debility, etc., are symptoms which may be due to any one
of a number of different conditions. Sometimes nothing more is known, but whenever possible, give the disease which caused the
symptom.

Manner of Death : Deaths not due to external cause should be identified as ‘Natural’. If the cause of death is known, but it is not
known whether it was the result of an accident, suicide or homicide and is subject to further investigation, the cause of death
should invariably be filled in and the manner of death should be shown as ‘Pending investigation’.
 FORM NO. 4A
(See Rule 7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(For non-institutional deaths. Not to be used for still births)
To be sent to Registrar along with Form No. 2 (Death Report)

I hereby certify that the deceased Shri/Smt/Km…………………………………………………… son/wife/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 at Death
If 1 year or more, If less than 1 year, age If less than one month, If less than one day, age
age in years in month age in days in hours
3. Male
4. Female

CAUSE OF DEATH Interval between onset

and death approx.
I (a) ……………………………………..
Immediate cause due to (or as a consequences of)
State the disease, injury or complication which
caused death, not the mode of dying such as heart
failure, asthenia, etc.

Antecedent cause (b) ……………………………………..

due to (or as a consequences of)
Morbid conditions, if any, giving rise to the above
cause, stating underlying conditions last

(c) ……………………………………..
II
Other significant conditions contributing to the death ….……………………………………..
but not related to the disease or condition causing it
….……………………………………..

If deceased was a female, was pregnancy the death associated with? 1. Yes 2. No
If yes, was there a delivery? 1. Yes 2. No

Name and signature of the Medical Practitioner certifying the cause of death

Date of verification ………………………………………………………………….

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.
 MEDICAL CERTIFICATE OF CAUSE OF DEATH
Directions for completing the form

Name of deceased : To be given in full. Do not use initials. If deceased is an infant, not yet named at time of death, write ‘Son of
(S/o)’ or ‘Daughter of (D/o)’, followed by names of mother and father.

Age : If the deceased was over 1 year of age, give age in completed years. If the deceased was below 1 year of age, give age in
months and if below 1 month give age in completed number of days, and if below one day, in hours.

Cause of Death : This part of the form should always be completed by the attending physician personally.

The certificate of cause of death is divided into two parts, I and II. Part I is again divided into three parts, lines (a) (b)
(c). If a single morbid condition completely explains the deaths, then this will be written on line (a) of Part I, and nothing more
need be written in the rest of Part I or in Part II, for example, smallpox, lobar pneumonia, cardiac beriberi, are sufficient cause of
death and usually nothing more is needed.

Often, however, a number of morbid conditions will have been present at death, and the doctor must then complete the
certificate in the proper manner so that the correct underlying cause will be tabulated. First, enter in Part I(a) the immediate cause
of death. This does not mean the mode of dying, e.g., heart failure, respiratory failure, etc. These terms should not be appear on
the certificate at all since they are modes of dying and not causes of death. Next consider whether the immediate cause is a
complication or delayed result of some other cause. If so, enter the antecedent cause in Part I, line (b). Sometimes there will be
three stages in the course of events leading to death. If so, line (c) will be completed. The underlying cause to be tabulated is
always written in last in Part I.

Morbid conditions or injuries may be present which were not directly related to the train of events causing death but
which contributed in some way to the fatal outcome. Sometimes the doctor finds it difficult to decide, especially for infant deaths,
which of several independent conditions was the primary cause of death; but only one cause can be tabulated, so the doctor must
decide. If the other diseases are not effects of the underlying cause, they are entered in Part II.

Do not write two or more conditions on a single line. Please write the names of the diseases (in full) in the certificates
as legibly as possible to avoid the risk of their being misread.

Onset : Complete the column for interval between onset and death whenever possible, even if very approximately, e.g., “from
birth” “several years”.

Accidental or violent deaths : Both the external cause and the nature of the injury are needed and should be stated. The doctor or
hospital should always be able to describe the injury, stating the part of the body injured, and should give the external cause in full
when this is shown. Example : (a) Hypostatic pneumonia; (b) Fracture of neck of femur; (c) Fall from ladder at home.

Maternal deaths : Be sure to answer the question on pregnancy and delivery. This information is needed for all women of child-
bearing age, even though the pregnancy may have had nothing to do with the death.

Old age or senility : Old age (or senility) should not be given as a cause of death if a more specific cause is known. If old age was
a contributory factor, it should be entered in Part II. Example : (a) Chronic bronchitis, II old age.

Completeness of information : A complete case history is not wanted, but, if the information is available, enough details should be
given to enable the underlying cause to be properly classified.

Example : Anaemia – Give type of anaemia, if known. Neoplasm – Indicate whether benign or malignant, and site, with site of
primary neoplasm, whenever possible, Heart disease – Describe the condition specifically; if congestive heart failure, chronic on
pulmonale, etc., are mentioned, give the antecedent conditions. Tetanus – Describe the antecedent injury, if known. Operation –
State the condition for which the operation was performed. Dysentery – Specify whether bacillary, amoebic, etc., if known.
Complications of pregnancy or delivery – Describe the complication specifically, Tuberculosis – Give organs affected.

Symptomatic statement : Convulsions, diarrhea, fever, ascites, jaundice, debility, etc., are symptoms which may be due to any one
of a number of different conditions. Sometimes nothing more is known, but whenever possible, give the disease which caused the
symptom.