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4a Death

The document is a medical certificate of cause of death for non-institutional deaths, which must be sent to the Registrar along with a death report. It includes sections for detailing the deceased's information, cause of death, and medical practitioner's certification. The form also provides instructions for the medical practitioner and includes a section for the relative of the deceased.

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244 views1 page

4a Death

The document is a medical certificate of cause of death for non-institutional deaths, which must be sent to the Registrar along with a death report. It includes sections for detailing the deceased's information, cause of death, and medical practitioner's certification. The form also provides instructions for the medical practitioner and includes a section for the relative of the deceased.

Uploaded by

pan card
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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FORM NO.

4A
(See Rule 7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(For Non-Institutional deaths. Not to be used for stillbirths)
To be sent to Registrar along with Form No.2 (Death Report)
I hereby certify that the deceased Shri/Smt/Kum………………………… son of/wife of/daughter
of …………………………….resident of ……………………was under my treatment from ……………
to …………………. and he/she died on ………………………………at…………..A.M./P.M.

NAME OF DECEASED For use of


Age at Death Statistical
Age in completed If less than 1 If less than one If less than one Office
Sex
years year, age in month, age in day, age in Hours
Months days
3. Male
4. Female
CAUSE OF DEATH Interval between
onset & death
Approx
I. Immediate cause
……………………..
State the disease, injury or complication
which Caused death, not the mode of dying (a) …………………
due to (or as ………………
such as Heart failure, asthenia, etc.
consequences of)
Antecedent cause ……………………..
Morbid conditions, if any, giving rise to the (b)………………….
above Cause, stating underlying conditions due to (or as ………………
last consequences of) ……………………..
………………
II. (c)........................
……………………..
Other Significant conditions contributing to the
Death but not related to the diseases or conditions ........................... …………………….. ……………..
causing it. ...........................
……………..
If deceased was a female, was pregnancy the death
associated with? 1. Yes 2. No
If yes, was there a delivery? 1. Yes 2. No

Name and Signature of the Medical Practitioner certifying the Cause of Death.
Date of Verification:………………………………………………………………………….

SEE REVERSE FOR INSTRUCTIONS


(To be detached and handed over to the relative of the deceased)

Certified that Shri/Smt/Kum............................................... S/W/D of Shri………………………


R/O……………………………… was under my treatment from…………….to…………….and he/she
expired on ……………at ………………A.M./P.M.

Doctor:…………………………………..
(Signature and address of Medical
Practitioner/Medical attendant with
Registration No.)

21

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