CHANDIGARH ADMINISTRATION REGISTRAR BIRTH AND DEATH Application for Issue of Death Certificate(s) FOR OFFICE USE ONLY Total Amount ___________ To Number of Copies _______ The Registrar, Receipt Number _________ Births and Deaths, U.T., Chandigarh. Dated : ______/_____/____ Sir, Kindly issue me the Death Certificate(s) as per details given below : 1. Date of Death (dd/mm/yyyy): _______/_______/________ 2. Sex : Male Female (Tick one) 3. Full Name of the Deceased: ____________________________________________ 4. Place of Death (Complete Address) : _____________________________________ 5. Father's Husband's Name of the Deceased: _________________________________ 6. Permanent Address at the time of admission in Hospital: ______________________ 7. Place of Cremation: ___________________________________________________ 8. C.R. No. if the deceased was admitted in the Hospital : _______________________ 9. Relation of Applicant with Deceased (Father/Mother/Relative): ________________ 10. Registration Number (if applicant knows) _________________________________ e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 1 of 2 CHANDIGARH ADMINISTRATION REGISTRAR BIRTH AND DEATH e-JAN SAMPARK 11. Name of Death (with application on bond Paper) ___________________________ FOR OFFICE USE ONLY Instructions to Dealing Hand in case of any correction filed by the applicant : Corrected Particulars with the date of correction: Name of Deceased: ____________________________________________ Sex: _________ (DOC: ____/____/____) Date of Death: _____/_____/_____ (DOC: ____/____/____) Father's/Husband's Name: ___________________ (DOC: ____/____/____) Place of Birth: ___________________________ (DOC: ____/____/____) DOC -Date of Correction Signature of Receiver with Date of receiving ______________ ______/______/_______ e -JAN SAMPARK : Information Gateway of Chandigarh Administration Page : 2 of 2
