No.... ASANSOL MUNICIPAL CORPORATION FORM OF APPLICATION FOR DEATH CERTIFICATE To Affix here The ________________________________ 25 P. Court fees ASANSOL MUNICIPAL CORPORATION Stamp. Respected Sir, I am furnishing below the particulars of death for obtaining the death certificate: 1. Date of application ____________________________________________________ 2. Name and residence of applicant _________________________________________ 3. Name of the deceased __________________________________________________ 4. Name of the deceased father / husband _____________________________________ 5. Date of death _________________________________________________________ 6. Age at death __________________________________________________________ 7. Place of death _________________________________________________________ 8. Cause of death ________________________________________________________ [Please enclose here with the post mortom report in the case of accidental death] 9. Date of Registration ____________________________________________________ 10. Ordinary searching fee deposited __________________________________________ 11. Deposited Rs. ______________________ vide M.R.No. _______________________ Name of the applicant (In Block Letter) Address: Signature of the applicant S.o/ W.o. No.... Name of the applicant: Date of application: Fees Receiving Date: Monday, Wednesday, Friday Signature of the receiving clerk 10.30 A.M to 2 P.M. with office seal and date Downloaded from www.asansolmycity.com
