GOVERNMENT OF NATIONAL CAPITAL TERRITORY OF DELHI Statisticall Information Form No. 3 STILL BIRTH REPORT This part to be detected and sent for statistical processing 7 a Name of Town/Village b Is it a town or village? (Tick the appropriate entry below) Village c d 8 9 10 11 1 -Government 2 -Private or Non-Government 3 4 5 12 (Columns to be filled are over, Now put signature at left) e.g. if studies upto class VII but passed only VI write class VI) (tick the appropriate entry ) this birth (in completed years) Age of the mother at the time of Cause of foetal death(if known) Mother's level of education:(enter the completed level of education Type of attention at delivery Duration of pregnancy(in weeks) Relatives or others Doctor, Nurse or Trained midwife Name of District Name of State To be filled by the Informant Town or village of Residence of the mother :(Place where the mother usually lives. This can be Town Different from the place where the delivery occurred. The house address is not required to be entered) Traditional Birth Attendent Institutional Institutional --Sex 2.Female 1.Hospital/Institution 2.House Name & Signature of the Registrar and Stamp Code No. Date of Birth Registration Unit Registration No. Place of Birth (To be filled by the Registrar) 1.Male Registration Date Tehsil Code No. Town/Village Code No. Name of district Code No.
