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FORM No.2
DEATH REPORT
Legal Information |
DEATH REPORT Statistical
Information |
FORM NO. 2 |
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To be filled by the informant 1.
Date of Death : (Enter the exact day)................... Month
& year the death took place e.g.1.1.2000 2.
Name of the Deceased........................................ (a)
Father’s/Husband’s Name.................................
3.
Sex of the deceased.............................................
(Enter
“male” or ‘female’ do not use abbreviations) 4.
Age of the deceased.............................................. (
in completed years) 5.
Place of death : ( Tick the appropriate
entry 1,2 or 3 below & give the name of the hospital/institution or
the address of the house where the death took place.
If other place give location)
Institution
6.
Informant’s Name ...............................................
Address...............................................................
(After completing all columns 1 to 17,informant will put date and
signature here) Date
Signature or left thumb mark of the informant |
To
be filled by the informant 7.
Town or village of Residence of the deceased : (Place
where the deceased actually lived. This can be different from the place
where the death occurred. The house address is not required to be entered)
a)
Name of Town / Village b)
Is it a town or Village (Tick the appropriate entry below) 1.
Town
2. Village....................... c)
Name of District.....................................
d)
Name of State ........................................ 8.
Religion (Tick the appropriate entry below) 1.
Hindu
2. Muslim 3. Christian
....................................................................................... 9.Occupation of the deceased....................................... ( If no occupation write Nil) 10.
Type of medical attention received before
death (Tick the appropriate entry below) 1.
Institutional ................................................... 2.
Medical attention other than institution 3.
No medical attention........................... |
To be filled by the informant 11.
Was the cause of death medically certified ?
(Tick the appropriate entry below)
1. Yes................
2. No......................... 12.
Name of Disease or Actual cause of Death (For all deaths
irrespective of whether medically certified or not
......................... ................................................................
............. 13.
In case this is a female death, did the death occur while pregnant, at
the time of delivery or within 6 weeks after the end of pregnancy
Tick the appropriate
entry below 1.
Yes ....................
2. No..................... 14.
If used to habitually smoke – for
How many years........................................ 15.
If used to habitually chew tobacco in any form –
for how many years.............
16.
If used to habitually chew arecanut in any form (including pas
masala)for how many years................................... 17.
. If used to
habitually drink alcohol for
how many years................................... |
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To
be filled by the Registrar Registration No..................Registration Date.......... Registration Unit.....................................................
Town/Village.....................District........................
Remarks, if any Name
& Signature of the Registrar |
To
be filled by the Registrar Name
Code No. District................................................................
Tahsil...................................................................
Town/Village....................................................... Registration Unit................................................... |
To
be filled by the Registrar Registration No..................Registration Date.......... Date of Death................Sex 1. Male......2.Female.... Age.......................Years/Months/days/hours
Place of death 1.Hospital/Institution 2.House 4.
Other place................................................. Name
& Signature of the Registrar |