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 ....... A.M./P.M. NAME OF DECEASED For use of Statistical Office Sex Age of Death If 1 year or more, age in years If less than 1 year, age in Months If less than 1 month, age in Days If less than 1 day, age in Hours ..... 1. Male 2. Female State the disease, injury or complication which caused death, not the mode of dying such as heart failure, asthenia etc. Immediate cause I. CAUSE OF DEATH ........... Interval between on set & death approx. II. Other significiant conditions contributing to the death but not related to the disease or conditions causing it Antecedent cause Morrid conditions, if any, giving rise to the above Cause, stating underlying condition last .......... .......... .......... .......... ..... ..... ..... ..... Manner of Death How did the injury occur ? 1. Natural 2. Accident 3. Sucide 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 RESERVE FOR INSTRUCTIONS (To be detached and handed over to the relative of the deceased) Certified that Shri./Smti./kum................... S/W/D of Shri .......... R/O ..................... was admitted to this Hospital on ................. and expired on ........... Doctor ............ Medical Supdt. Name of Hospital)
