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FORM NO.3 STILL BIRTH REPORT |
STILL BIRTH
REPORTIn the case of multiple births fill, in a FORM NO.3 separate form for each child and write Statistical
Information Twin birth of Triple birth etc. as the case may be. In the
remarks column in the box below left. |
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To
be filed by the informant 1.
Date of Birth: (Enter the exact day, month And
year................................................... (e.g.1.1.2000) 2.
Sex: (Enter ‘male or ‘female’).................... (Do
not use abbreviation) 3.
Name of the father...................................... (Full
name as usually written) 4.
Name of the mother.................................... (Full
name as usually written) 5.
Place of birth: (tick the appropriate entry below and give the name of
the Hospital/ Institution of the address of the house where the birth took
place) 1.
Hospital/ Name.............................
Institution 2.
House Address..............................
6.
Informant's name....................................... Address.......................................................
(After completing all columns
1 to 12, 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 mother: (Please where the
mother usually lives. This can be different
from the place where the delivery 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. Age of the
mother (in completed years) at the time of this birth
............................................... 9.
Mother’s level of education: (Enter
the completed level of
education.................................................................................... e.g.
if studied upto class VII but passed only
class VI, write class VI) 10.
Type of attention at delivery: (Tick the appropriate entry below) 1.
Institutional – Government 2.
Institutional – Private or Non-Government 3.
Doctor, Nurse or Trained midwife 4.
Traditional Birth Attendant 5.
Relative or others 11.
Duration of pregnancy (in weeks)
............................................................................................ 12.Cause of foetal death: (if known)
............................................................................................... (Columns
to be filled are over. Now
put signature at left) |
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To
be filled by the Registrar Registration No: .......................Registration Date::
........... Registration Unit: ......................................... Town/Village: ............... District.:................... Remarks: (if any) Name
and Signature of the Registrar |
To
be filled by the Registrar Name
Code No.
Registration No: .............. Registration Date: ............ District: .................................
Date of Birth:............. Sex:1. Male 2. Female Tahsil: ..................................
Place of Birth: 1. Hospital/Institution 2. House Town/Village: .....................
3. Other Place ............................. Registration Unit: .............. Name
and Signature of the Registrar |