ORDINARY APPLICATION FOR ISSUE OF DEATH EXTRACT Corporation of Chennai Health Department To THE HEALTH OFFICER, Corporation of Chennai, Chennai-600 003. Sir, Please furnish me ---------------------------------- copy/copies of Death extract, as per particulars furnished hereunder: 1. Name of the deceased & age 2. Date of Death 3. Place of Death (a) Name of Hospital & Address (b) Name of Nursing Home & Address (c) At home and Address 4. Residential address at the time of Death Dated................. Yours faithfully, B. & D. No ------------------ Date of Death ------------------- Received Rs.-----------------------only ACKNOWLEDGEMENT Received an application for the issue of Death extract of -----------------------------------------------------------------at from -------------------------------along with Receipt No.---------------------Dt.--------------------. The party is advised to produce this receipt at this Office after 7 working days and collect the death extract applied for. If the entries are not found the party will be so informed after a through search as per the particulars furnished in the application. Signature
