FORM NO.2 DEATH REPORT DEATH REPORT FORM NO. 2 Legal information Statistical Information This part to be added to the Death Register This part to be detached and sent for statistical processing To be filled by the informant To be filled by the informant To be filled by the Informant 1. Date of Death: (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. Name of Father/Husband of the deceased: 6. 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/ Name: Institution 2. House Address: 3. Other Place 7. Informant's name: Address: (After completing all columns 1 to 1a, Informant will put date and Signature here) Date: Signature or left thumb mark of the informant 8. Town or village of Residence of the deceased: (Place where the deceased actually lives. 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/village: (Tick the appropriate entry below) 1. Town 2. Village (c) Name of District: (d) Name of State: 9. Religion: (Tick the appropriate entry below) 1. Hindu 2. Muslim 3. Christian 4. Any other religion: (write the name of the religion) 10. Occupation of the deceased: (if no occupation write 'Nil') 11. Type of medical attention received before death: (Tick the appropriate entry below) 1. Institutional 2. Medical attention other than institution 3. No medical attention 12. Was the cause of death medically certified? : (Tick the appropriate entry below) 1. Yes 2. No 13. Name of Decease or Actual Cause of Death: (For all deaths irrespective of whether medically certified or not) 14. 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 15. If used to habitually smoke, for how many years? 16. If used to habitually chew tobacco in any form for how many years? 17. If used to habitually chew areca nut in any form (including pan masala)- for how many years? 18. If used to habitually drink alcohol- for how many years? Columns to be filled are over. Now put signature at left) 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 filled by the Registrar Name Code No. District: Tehsil: Town/Village: Registration Unit: To be filled by the Registrar Registration: Registration Date: Date of Death: Sex : 1. Male 2. Female Age: Years/mon\hs/days/hours Place of Death: 1. Hospital/Institution 2. House 3. Other Place Name and Signature of the Registrar
