FORM NO. 4A (See Rule 7) MEDICAL CERTIFICATE OF CAUSE OF DEATH (For non-instutional deaths. Not to be used for still births) To be sent to Registar along with Form No.2 (Death Report) I hereby certify that the deceased Shri/Smti./Kum. .............. son of/wife of/daughter of ........... resident of ............... was under my treatment from .......to ........ and he/she died on at ..... A.M./P.M. NAME OF DECEASED For use of Statistical Office Sex Age of Death Age in completed 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 (a) ............... due to (or as a consequences of) (b) .............. due to (or as a consequences of) (c) .............. II. ............. ................ Other significiant conditions contributing to the death but not related to the disease or conditions causing it Morrid conditions, if any, giving rise to the above Cause, stating underlying condition last Immediate cause I. State the disease, injury or complication which caused death, not the mode of dying such as heart failure, asthenia etc. Antecedent cause ........... .......... .......... .......... .......... Interval between on set & death approx. 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 Practioner certifying the cause of death Date of certification ......................... 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 under my treatment from ..... to ..... and he/she expired on ...... at ...... A.M./P.M. Doctor ............ Signature and address of Medical Practioner/ Medical Attendant with Registration No.
