Death Registration Form Applicant should fill all the required death details below Death Registration Form Applicant should fill all the required death details below Registration Place: Town: District: 1. Date of Death: 2. Name of the Deceased: 3. Father/Husband Name: 4. Gender of Deceased: 5. Age of Deceased: 6. Address of Deceased: 7. Permanent Address of Deceased: 8. Informer Name and Address: 10. Religion : 9. City/Village of the Deceased : 11. Occupation of the Deceased : 12. Treatment given before Death: 13. Has the reason of death If Yes from how many years: 16. Addicted to Smoking (Yes/No) Medically Certified: 14. Name of the Disease/Cause for Death: due to any of the following Reasons: 17. Addicted to Tobacco (Yes/No) If Yes from how many years: 18. Addicted to Supari (Yes/No) If Yes from how many years: 19. Addicted to Alcohol (Yes/No) If Yes from how many years: 15. Incase of Female it was Death : For Office Use Only For Office Use Only Registrar name and signature Registrar name and signature Registration No: Registration Date: Name: Taluk: City/Village: Date of Death: Age: Place of Death: Gender: Registrar name and signature Date:
