CHANDIGARH ADMINISTRATION REGISTRAR BITH & DEATH e-JAN SAMPARK FORM NO. 2 DEATH REPORT DEATH REPORT Legal Information Statistical Information This part to be added to the Birth Register This part to be detached and sent for statistical processing To be filled by the informant 1. Date of Death: (Enter the exact day, month and year) 2. Name of the Deceased (full name as usually written) 3. Sex of the Deceased : (Enter male or female) 4. Age of the deceased : (if the deceased was over 1 year of age, give age in Completed years. If the deceased was below 1 year of age, give age in months, and if below 1 month Give age in completed number of days. And if below one day, in hours) 5. Place of Death: (Tick the appropriate entry 1 or 2 below and give the name of the hospital / Institution or the address of the house where the birth took place) 1. Hospital/ Name: Institution 2. House Address: 6. Informant's name: Address: (After completing all columns 1 to 17, informant will put date and signature here) Date: Signature or Left thumb mark of the Informant To be filled by the informant 7. Town or Village or Residence of the deceased : (Pleace where the deceased actually lived. This can be different from the place where the delivery occurred. The house address is not required to be entered) ( a ) Name of Town/ Village) ( b ) Is it a town or village (Tick the appropriate) 1. Town 2. Village ( c ) Name of District : ( d ) Name of State : 8. Religion of the family : (Tick the appropriate) 1. Hindu 2. Muslim 3. Christian 4. Sikh 5. Any other religion : (Write the name of the religion) 9. Occupation of the deceased: (if no occupation write 'NIL') 10. Type of medical attention received before death: (Tick the appropriate entry below) 1. Institutional 2. Medical attention other than Institution 3. No medical attention To be filled by the informant 11. Was the cause of death medically certified? : (Tick the appropriate entry below) 1. Yes 2. No 12. Name of Disease or Actual Causes of Death : (For all deaths irrespective of whether medically certified or not) 13. In case this is a female death , did the death occur while pregnant, at the time of delivery or within 6 weeks after the end of pregnancy: Tick the appropriate entry below 1. Yes 2. No 14. If used to habitually smoke for how many years? 15. If used to habitually chew tobacco in any form (Including pan masala) for how many years? 16. If used to habitually chew arecanut in any form (Including pan masala) for how many years? 17. If used to habitually drink alcohol for how many years? (Columns to be filled are over. Now put sign at left) e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 1 of 2 CHANDIGARH ADMINISTRATION REGISTRAR BITH & DEATH e-JAN SAMPARK (FOR OFFICE USE ONLY) 1. Total fee received Rs. _______________________________ 2. Receipt No. _______________________________________ 3. Dated ____________________________________________ 4. Late Fee (if Any) Rs. ___________________ Compounding Fee Rs. ________________ The information is being given after the 21/ 30 days of the occurrence but within period of ___________ may register with a late fee of Rs. ___________ and compounding Fee of Rs. ______ on basis of affidavit worth Rs. 3/- by attested by the magistrate/ Notary public / order of the Sub Divisional Magistrate, Chandigarh vide order no. _________________ Dated ________ District Registrar Birth and Deaths U.T. , Chandigarh To be filled by the Registrar Name Code No District : Tehsil : Town/ Village : Registration Unit : To be filled by the Registrar Registration No: Registration Date: Date of Birth : Sex : 1. Male 2. Female Age : Years/ Months/ Days/ Hours Place of Birth : 1. Hospital / Institution 2. House 3 Other Places Name and Signature of the Registrar e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 2 of 2 To be filled by the Registrar Registration No: Registration Date: Registration Unit: Town Village: District: Remarks : (if Any) Name and Signature of the Registrar
