FORM NO.2 DEATH REPORT Legal Information This part to be added to Death Register DEATH REPORT Statiscal Information To be filled by the informant 1. Date of Death : 2. Name of the deceased :3. Sex of the deceased : 4. Age of the deceased :5. Name of the Father/Husband/Mother 6. Place of death : i. Hospital/Institution Name : ii. House : Address: iii. Other place : 7. Informant's name : Address : Date :Signature or left thumb mark of the informant To be filled by the informant8. Town or village of Residence of the deceased : ( a) Name of Town/Village : 1. Town 2. Village ( c) Name of District : ( d) Name of State :9. Religion (Tick the appropriate entry below): 1. Hindu 2. Muslim 3. Christian 4. Any other religion (write name of religion)10.Occupation of the deceased : appropriate entry below) 1. Institutional : 2. Medical attention other than institution : 3. No medical attention : 1. Yes 2. No 13. Name of Disease or actual cause of Death : after the end of pregnancy: (Tick the appropriate entry below) 1. Yes 2. No many years ? (including panmasala) for how many years ?12. Was the cause of death medically certified ? To be filled by the Register Registration No. : Registration Date : Registration unit : Town/Village : District: Remarks (if any) Name and signature of Registrar To be filled by the Register District : Tahsil : Town /Village : Registration unit : Date of Death : Place of Death 1. Hospital 2. Institution 3. House 4. Other Name and signature of the Registrar
