Application form for Death Certificate 1. a) Name of Applicant : ............... b) Relationship with Deceased Person : ............... 2. Name of the deceased : ............... 3. Date of Death : ............... 4. Place of Death : ............... 5. Death Report from Local Gaonburah/Local P.H.C. / Civil Hospital/Nursing Home : ............... 6. Affidavit duly signed by the Magistrate if delayed for More than on year : ............... ............... Signature of Applicant Date of Application:........ FOR OFFICE USE (Circle Officer's Report) 1. Full particulars of Deceased Person : .............. ............... ............... ............... 2. Signature of Lat Mandal : ............... Recommended/Not Recommended Seal of Office Signature of Circle Officer ..................................... Enclosed: 1. Affixed Rs1.10 paise court fee stamp. 2. Death Report from Local Gaonburah/Local P.H.C/Civil Hospital/Nursing Home 3. Circle Officer's report. 4. Treasury Challan Copy.
