FORM NO.2 DEATH REPORT Legal information This part to be added to the Death Register To be filled by the informant 1. Date of Birth: (Enter the exact day, month and year the death took place e.g. 1-1-2000) 2. Name of the deceased: (Full name as usually written) 3. Sex of the deceased: (Enter "male" or "female" do not use abbreviation) 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, 2 or 3 below and give the name of the hospital/Institution or the address of the house where the death took place. If other place, give location ). 1. Hospital/Institution Name 2. House Address 3. Other Place 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 Registrar Registration No: Registration date: Registration Unit Town/Village: District Remarks. (if any ) Name and Signature of the Registrar To be detached and send for statistical processing DEATH REPORT Statistical information This part to be detached and sent for statistical processing To be fill by the informant 7. Town or village of residence of the deceased: (Place where the deceased usually lived. This can be different from the place where the death 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 entry below) 1.Town 2.Village (c) Name of District: (d) Name of State: 8. Religion: (Tick the appropriate entry below) 1. Hindu 2. Muslim 3. Christian 4. 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 Registrar Name : Code No. District : Tahsil : Town/Village : Registration Unit : FORM NO. 2 (See Rule 5) DEATH REPORT FORM FORM NO.2 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 Cause 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 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 signature at left) Registration No: Registration date: Date of Death: Sex: 1. Male 2. Female Age: Years/months/days/hours Place of Birth: 1. Hospital/Institution 2. House 3. Other place Name and Signature of the Registrar
