“ FORM NO.1 FORM NO.

1
(See rule 5) (See rule 5)
BIRTH REPORT BIRTH REPORT
Legal information Statistical information
[SEE REVERSE FOR INSTRUCTIONS] [SEE REVERSE FOR INSTRUCTIONS]
This part to be added to the Birth Register This part to be detached and sent for statistical processing

To be filled by the informant To be filled by the informant

1. Date of Birth : D D - M M - Y Y Y Y 10. Town or Village of Residence of the mother (Place

where the mother usually lives. This can be different
2. Sex (Enter “Male” or “Female” or “Transgender person”) : from the place where the delivery occurred. Tick
appropriate entry “Town” or “Village” and write its
3. Child’s Details (If not named, leave blank) :- name):
(a) Name, if any : First Name Middle Name Last Name Town or Village: Sub-district:
(b) Aadhaar No. (if available): District: State or Union Territory:
PIN Code:
4. Father’s Details:-
(a) Name: First Name Middle Name Last Name 11. For Religion [Enter appropriate religion “Hindu” or
(b) Muslim” or “Christian” or “Sikh” or “Buddhist” or “Jain” or
Aadhaar No. (if available):
(c) “Other (Please specify)”]
Mobile No: (a) Religion of Father:
(d) Email Id: (b) Religion of Mother:
5. Mother’s Details:-

To be detached and sent for statistical processing

(a)
Name: First Name Middle Name Last Name 12. Father’s level of education:
(b)
Aadhaar No. (if available): 13. Mother’s level of education:
(c)
Mobile No:
(d)
Email Id: 14. Father’s Occupation:

6. Address of parents at the time of Birth of the Child: House No: 15. Mother’s Occupation:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District: 16. Age of the mother (in completed years) at the time
State or Union Territory: PIN Code: of marriage (If married more than once, age at first
marriage is to be written):
7. Permanent address of parents: House No:
Locality: Ward number (in case of town and if available): 17. Age of the mother (in completed years) at the time
Town or Village: Sub-district: District: of this birth :
State or Union Territory: PIN Code:
18. Number of children born alive to the mother so far
8. Place of birth (Tick the appropriate entry 1 or 2 or 3 below and give the name and address of including this child (Number of children born alive to
the “Hospital / Institution” or the address of the “House” or ‘Other place” where the birth took include also those from earlier marriage(s), if any) :
place) :
1.Hospital / Institution Name : 19. Type of attention at delivery (Tick the appropriate
2. House 3. Other place Address : House No: entry below):
Locality: Ward number (in case of town and if available): 1. Institutional-Government
Town or Village: Sub-district: District: 2. Institutional – Private or Non-Government
State or Union Territory: PIN Code: 3. Doctor, Nurse or Trained Midwife
4. Traditional Birth Attendant
9. Informant’s Details: 5. Relatives or others
(a) Name: First Name Middle Name Last Name 20. Method of Delivery (Tick the appropriate entry below):
(b)
Aadhaar No. (if available): 1. Natural
(c) 2. Caesarean
Mobile No: 3. Forceps/Vacuum
(d)
Email Id:
(e)
Address : House No: 21. Birth Weight (in kgs.) (if available) :
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District: 22. Duration of pregnancy (in weeks) :
State or Union Territory: PIN Code:
DECLARATION:
I have furnished true information to the best of my knowledge and belief. I am aware of the penalties
under section 23 of the Registration of Births and Deaths Act, 1969 (amended in 2023) for submitting
false information. Also, I give consent, under Aadhaar (Targeted Delivery of Financial and Other
Subsidies, benefits and Services) Act, 2016, for authenticating identity by way of Aadhaar
authentication. (In the case of multiple births, fill in a separate form
for each child and write 'Twin birth' or 'Triple birth'
(After completing all columns 1 to 22, etc., as the case may be, in the remarks column in
informant will put date and signature) the box below left.)

Date: D D - M M - Y Y Y Y Signature or (Columns to be filled are over. Now put signature at left)
left thumb mark of the informant

To be filled by the Registrar To be filled by the Registrar

Name Code No.
Registration No. : District
Registration Date: D D - M M - Y Y Y Y
Sub-District
Registration Unit :
Town / Village: Town/Village :
Sub-District: Registration Unit :
District: Registration No. :
Remarks ( if any): Registration Date: D D - M M - Y Y Y Y

Date of Birth : D D - M M - Y Y Y Y

Sex : Male / Female / Transgender person

Place of Birth: 1. Hospital/Institution 2. House 3. Other
place

Name and Signature of the Registrar Name and Signature of the Registrar
 Instructions for completing the Form 1: BIRTH REPORT

Item No. Instructions

1 Date, wherever it occurs, is to be provided in dd-mm-yyyy format, where dd is date in two digits, mm
is month in two digits and yyyy is year in four digits. Wherever the date is written in words it should
be written in full e.g 01-01-2023 shall be written as First January two thousand twenty three. Use
only 'Arabic numerals' such as 0,1,2,3,4,5,6,7,8,9 for recording dates and other numerical entries.
2 Enter “Male” or “Female” or “Transgender Person”. Do not use abbreviation.

3,4,5,9 Name, wherever it occurs, is to be provided in the format of [first name] [middle name] [last name]
where full name (not abbreviation) to be written in capital letters and first name is mandatory. There
should be minimum two characters in either [first name] or [middle name] or [last name]. If child is
not named, leave blank.
Birth can be registered without name of the child. However, name of child can be inserted, free of
charge, within 12 months of registration (Refer Rule 10 of State Rules).
6,7,8,9 Address, wherever it occurs, shall contain the name of State or Union Territory, District, Sub-district,
Town or Village, Ward number (in case of town and if available), Locality, House number and PIN
Code.
8 Tick the appropriate entry for place of birth
1. Hospital / Institution
2. House
3. Other place
Give the name and address of the “Hospital / Institution” or the address of the “House” or ‘Other
place” where the birth took place.
10 Town or Village of residence of the mother: Place where the mother usually lives. This can be
different from the place where the delivery occurred. The house address is not required to be
entered.
12,13 Level of Education – Write one of following—
1.Pre- 6.Class 5 11.Class 10 16. Bachelor / 21. Literate without
Primary Undergraduate formal education

2.Class 1 7.Class 6 12.Class 11 17. PG Diploma 22. Illiterate

3.Class 2 8.Class 7 13.Class 12 18. Master / Post
graduate
4.Class 3 9.Class 8 14.ITI 19. M.Phil
5.Class 4 10.Class 9 15.Diploma / 20. Doctorate & above
Certificate
(Enter the completed level of education e.g. if studied upto class VII but passed only class VI, write
class VI)
14, 15 Occupation - Write one of following—
1. Cultivator
2. Agriculture Labourer
3. Daily Wages Earner(Other than Agriculture Labourer)
4. Single/Family Worker/Self Employed
5. Employer
6. Government Employee
7. Private Employee(Other than Domestic Helper)
8. Domestic Helper
9. Non-Worker

Note: The informant must ensure that no item in the Birth Report Form is left blank to the extent possible.
 FORM NO.1A ( Legal information) (See rule 5) FORM NO.1A Statistical information (See rule 5)
BIRTH REPORT FOR ADOPTED CHILD BIRTH REPORT FOR ADOPTED CHILD
[SEE REVERSE FOR INSTRUCTIONS] [SEE REVERSE FOR INSTRUCTIONS]
This part to be added to the Birth Register This part to be detached and sent for statistical processing
To be filled by the informant To be filled by the informant
1*. Date of Birth : D D - M M - Y Y Y Y
14. For Religion [Enter appropriate religion
2*. Sex (Enter “Male” or “Female” or “Transgender person”) : “Hindu” or Muslim” or “Christian” or “Sikh” or
Child’s details (If name is changed on adoption, write new name):- “Buddhist” or “Jain” or “Other (Please specify)”]
3.
(a) Name of the Child First Name Middle Name Last Name
(b) Aadhaar No. (if available): (a) Religion of Adoptive Father:
4*. Mother’s Details (If known):-
(a) Name: First Name Middle Name Last Name (b) Religion of Adoptive Mother:
(b)
Aadhaar No. (if available):
(c) 15. Adoptive Father’s level of education:
Mobile No:
(d) Email Id:
5*. Father’s Details(If known):- Adoptive Mother’s level of education:
16.
(a) Name: First Name Middle Name Last Name
(b)
Aadhaar No. (if available): Adoptive Father’s Occupation:

To be detached and sent for statistical processing

17.
(c)
Mobile No:
(d) Email Id:
18. Adoptive Mother’s Occupation:
6. Details of adoption deed / order:-
(a) Date: D D - M M - Y Y Y Y
(b) Number of Adoption deed / order:
7. Adoptive Mother’s Details:-
(a) Name: First Name Middle Name Last Name
(b) Aadhaar No. (if available):
(c)
Mobile No:
(d) Email Id:
1

8. Adoptive Father’s Details:-

(a) Name: First Name Middle Name Last Name
(b)
Aadhaar No. (if available):
(c)
Mobile No:
(d)
Email Id:
9. Address of adoptive parents as recorded in Adoption deed / order: House No:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
10. Permanent address of adoptive parents: House No: Locality:
Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
11*. Place of birth: (Tick the appropriate entry 1 or 2 or 3 below and give the name and address of the “Hospital /
Institution” or the address of the “House” or ‘Other place” where the birth took place) :
1.Hospital / Institution Name :
2. House 3. Other place Address : House No. Locality:
Ward number (in case of town and if available): Town or Village:
Sub-district: District:
State or Union Territory: PIN Code:
12. If adoption through agency write the address of the Adoption agency: House No:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
13. Informant’s Details:-
(a) Name: First Name Middle Name Last Name

(b) Aadhaar No.(if available):

(c) Mobile No:
Email Id:
(d)
Address : House No: Locality: Ward number (in case of town and if available):
(e)
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
*As contained in the original birth certificate.
DECLARATION: I have furnished true information to the best of my knowledge and belief. I am aware of the
penalties under section 23 of the Registration of Births and Deaths Act, 1969 (amended in 2023) for submitting
false information. Also, I give consent, under Aadhaar (Targeted Delivery of Financial and Other Subsidies,
benefits and Services) Act, 2016, for authenticating identity by way of Aadhaar authentication.
(After completing all columns 1 to 18,
informant will put date and signature)
Date: D D - M M - Y Y Y Y Signature or (Columns to be filled are over. Now put signature at left)
left thumb mark of the informant

To be filled by the Registrar To be filled by the Registrar

Registration No. : Name Code No.
District
Registration Date: D D - M M - Y Y Y Y
Sub-District
Registration Unit : Town/Village :
Town / Village: Sub-District: Registration Unit : Registration No. :
District: Registration Date: D D - M M - Y Y Y Y
Remarks ( if any): Date of Birth : D D - M M - Y Y Y Y
Sex : Male / Female / Transgender person
Place of Birth: 1. Hospital/Institution 2. House 3.
Other place

Name and Signature of the Registrar Name and Signature of the Registrar
Instructions for completing the Form 1A: BIRTH REPORT FOR ADOPTED CHILD

Item No. Instructions

1, 6 Date, wherever it occurs, is to be provided in dd-mm-yyyy format, where dd is date in two
digits, mm is month in two digits and yyyy is year in four digits Wherever the date is written in
words it should be written in full e.g 01-01-2023 shall be written as First January two thousand
twenty three.
If date of birth is unknown, record the date of birth as reflected in adoption order or deed, as
the case may be.
Use only 'Arabic numerals' such as 0,1,2,3,4,5,6,7,8,9 for recording dates and other
numerical entries.
2 Enter “Male” or “Female” or “Transgender Person”. Do not use abbreviation.

3,4,5,7,8,13 Name, wherever it occurs, is to be provided in the format of [first name] [middle name] [last
name] where full name (not abbreviation) to be written in capital letters and first name is
mandatory. There should be minimum two characters in either [first name] or [middle name]
or [last name].
9,10,11,12,13 Address, wherever it occurs, shall contain the name of State or Union Territory, District, Sub-
district, Town or Village, Ward number (in case of town and if available), Locality, House
number and PIN Code.
15,16 Level of Education – Write one of following—
1.Pre- 6.Class 5 11.Class 10 16. Bachelor / 21. Literate without
Primary Undergraduate formal education

2.Class 1 7.Class 6 12.Class 11 17. PG Diploma 22. Illiterate

3.Class 2 8.Class 7 13.Class 12 18. Master / Post
graduate
4.Class 3 9.Class 8 14.ITI 19. M.Phil
5.Class 4 10.Class 9 15.Diploma / 20. Doctorate & above
Certificate
(Enter the completed level of education e.g. if studied upto class VII but passed only class VI,
write class VI)
17,18 Occupation - Write one of following—
1. Cultivator
2. Agriculture Labourer
3. Daily Wages Earner(Other than Agriculture Labourer)
4. Single/Family Worker/Self Employed
5. Employer
6. Government Employee
7. Private Employee(Other than Domestic Helper)
8. Domestic Helper
9. Non-Worker

Note: The informant responsible for reporting birth event of adopted child shall be as per the Registration of Births
and Deaths Act, 1969 (amended in 2023).
The informant must ensure that no item in the form for Birth Report for Adopted Child is left blank to the extent
possible.
 FORM NO.2 (See rule 5) FORM NO.2 (See rule 5)
DEATH REPORT DEATH REPORT
Legal information Statistical information
[SEE REVERSE FOR INSTRUCTIONS] [SEE REVERSE FOR INSTRUCTIONS]
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
1. Date of Death D D - M M - Y Y Y Y 11. Town or village of Residence of the deceased (Place
2. :Deceased’s Details:- where the deceased usually lived. This can be different
(a) Name: First Name Middle Name Last Name from the place where the death occurred. Tick appropriate
entry “Town” or “Village” and write its name):
(b) Aadhaar No. (if available): Town or Village: Sub-district:
(c) Date of Birth (if available) : D D - M M - Y Y Y Y District: State or Union Territory:
(d) Age: PIN Code:
3. Sex (Enter “Male” or “Female” or “Transgender person”) :
12. Religion ( Enter appropriate religion “Hindu” or “Muslim” or
4. Mother’s Details:- “Christian” or “Sikh” or “Buddhist” or “Jain” or “Other
(a) Name: First Name Middle Name Last Name (Please specify)”):
(b) Aadhaar No. (if available):
13. Occupation of the deceased:
(c) Mobile No:
(d) Email Id:
14. Type of Medical Attention received before death (Tick

To be detached and sent for statistical processing

5. Father’s Details:- the appropriate entry below):
(a) Name: First Name Middle Name Last Name 1. Institutional
(b) 2. Medical attention other than Institution
Aadhaar No. (if available):
3. No Medical attention
(c) Mobile No:
(d) 15. Was the cause of death medically certified? (Tick the
Email Id:
appropriate entry below) :
6. Spouse’s (husband / wife) Details:- 1.Yes 2. No
(a) Name: First Name Middle Name Last Name
(b) 16. Name of Disease or Actual Cause of Death (For all
Aadhaar No.(if available):
deaths irrespective of whether medically certified or not) :
(c) D D - M M - Y Y Y Y
Date of Birth (if available) :
(d) Age (in completed years): 17. In case this is a female death, did the death occur
(e) Mobile No: while pregnant, at the time of delivery or within 6
(f) Email Id: weeks after the end of pregnancy (Tick the appropriate
entry below):
7. Address of the deceased at the time of death: House No: 1.Yes 2. No
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District: 18. If used to habitually smoke –
State or Union Territory: PIN Code: for how many years?

8. Permanent address of the deceased: House No: 19. If used to habitually chew tobacco in any form –
Locality: Ward number (in case of town and if available): for how many years?
Town or Village: Sub-district: District:
State or Union Territory: PIN Code: 20. If used to habitually chew arecanut in any form
(including pan masala) -
9. Place of death (Tick the appropriate entry 1 or 2 or 3 below and give the name and address for how many years?
of the “Hospital / Institution” or the address of the “House” or ‘Other place” where the death
took place) : If used to habitually drink alcohol -
1.Hospital / Institution Name : 21.
for how many years?
2. House 3. Other place Address : House No:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
10. Informant’s Details:-
(a) Name: First Name Middle Name Last Name
(b) Aadhaar No.(if available):
(c) Mobile No:
(d) Email Id:
(e) Address : House No.:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
DECLARATION: I have furnished true information to the best of my knowledge and belief. I am
aware of the penalties under section 23 of the Registration of Births and Deaths Act, 1969
(amended in 2023) for submitting false information. Also, I give consent, under Aadhaar (Targeted
Delivery of Financial and Other Subsidies, benefits and Services) Act, 2016, for authenticating
identity by way of Aadhaar authentication.
To the best of my knowledge and information, the detail of Aadhaar of the deceased is not
available.
(After completing all columns 1 to 21,
informant will put date and signature)
Date: D D - M M - Y Y Y Y Signature or left thumb mark of the informant (Columns to be filled are over. Now put signature at left)

To be filled by the Registrar To be filled by the Registrar

Registration No. : Name Code No.
District
Registration Date: D D - M M - Y Y Y Y
Registration Unit : Sub-District
Town / Village: Town/Village :
Registration Unit :
Sub-District:
Registration No. :
District:
Remarks ( if any): Registration Date: D D - M M - Y Y Y Y

Cause of Death (as per Form 4 / 4A): Date of Death : D D - M M - Y Y Y Y

Sex : Male / Female / Transgender person
Age of deceased:
Place of death : 1. Hospital/Institution 2. House 3. Other place

Name and Signature of the Registrar

Name and Signature of the Registrar
 Instructions for completing the Form 2: DEATH REPORT
Item No. Instructions
1 Date, wherever it occurs, is to be provided in dd-mm-yyyy format, where dd is date in two digits,
mm is month in two digits and yyyy is year in four digits Wherever the date is written in words it
should be written in full e.g 01-01-2023 shall be written as First January two thousand twenty
three. Use only 'Arabic numerals' such as 0,1,2,3,4,5,6,7,8,9 for recording dates and other
numerical entries.
2,4,5,6,10 Name, wherever it occurs, is to be provided in the format of [first name] [middle name] [last name]
where full name (not abbreviation) to be written in capital letters and first name is mandatory.
There should be minimum two characters in either [first name] or [middle name] or [last name].
3 Enter “Male” or “Female” or “Transgender Person”. Do not use abbreviation.

2(d) 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.

7,8,9,10 Address, wherever it occurs, shall contain the name of State or Union Territory, District, Sub-
district, Town or Village, Ward number (in case of town and if available), Locality, House number
and PIN Code.
9 For Place of death tick the appropriate entry
1. Hospital / Institution
2. House
3. Other place
Give the name and address of the “Hospital / Institution” or the address of the “House” or ‘Other
place” where the death took place.
11 Town or Village of the 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.
13 Occupation - Write one of following—
1. Cultivator
2. Agriculture Labourer
3. Daily Wages Earner(Other than Agriculture Labourer)
4. Single/Family Worker/Self Employed
5. Employer
6. Government Employee
7. Private Employee(Other than Domestic Helper)
8. Domestic Helper
9. Non-Worker

Note: The informant must ensure that no item in the Death Report Form is left blank to the extent possible.
 FORM NO.3 FORM NO.3
(See rule 5) (See rule 5)
STILL BIRTH REPORT STILL BIRTH REPORT
Legal information Statistical information
[SEE REVERSE FOR INSTRUCTIONS] [SEE REVERSE FOR INSTRUCTIONS]
This part to be added to the Still Birth Register This part to be detached and sent for statistical processing

To be filled by the informant To be filled by the informant

1. Date of Birth : D D - M M - Y Y Y Y 7. Town or village of Residence of the mother (Place

where the mother usually lives. This can be different from
2. Sex (Enter “Male” or “Female” or “Transgender person”) : the place where the delivery occurred. Tick appropriate
entry “Town” or “Village” and write its name):
3. Father’s Details:- Town or Village: Sub-district:
(a) Name: First Name Middle Name Last Name District: State or Union Territory:
(b) PIN Code:
Aadhaar No. (if available):
(c)
Mobile No:
(d)
Email Id: 8. Age of the mother (in completed years) at the time
4. of this birth :
Mother’s Details:-
(a)
(b) Name: First Name Middle Name Last Name 9. Mother’s level of education:
(c) Aadhaar No.(if available):

To be detached and sent for statistical processing

(d) Mobile No: 10. Type of attention at delivery (Tick the appropriate entry
Email Id: below):

Place of birth (Tick the appropriate entry 1 or 2 or 3 below and give the name and 1. Institutional-Government
5.
2. Institutional – Private or Non-Government
address of the “Hospital / Institution” or the address of the “House” or ‘Other place” where
3. Doctor, Nurse or Trained Midwife
the birth took place) : 4. Traditional Birth Attendant
1.Hospital / Institution Name : 5. Relatives or others
2. House 3. Other place Address : House No. Locality:
Ward number (in case of town and if available): Town or Village: Duration of pregnancy (in weeks) :
Sub-district: District: 11.
State or Union Territory: PIN Code: Cause of foetal death (if known):
12.
6. Informant’s Details:
(a) Name: First Name Middle Name Last Name
(b) Aadhaar No. (if available):
(c) Mobile No:
(d) Email Id:
(e) Address : House No:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code: (In the case of multiple births, fill in a separate form for
DECLARATION: each child and write 'Twin birth' or 'Triple birth' etc., as
I have furnished true information to the best of my knowledge and belief. I am aware of the the case may be, in the remarks column in the box
penalties under section 23 of the Registration of Births and Deaths Act, 1969 (amended in below left.)
2023) for submitting false information. Also, I give consent, under Aadhaar (Targeted Delivery
of Financial and Other Subsidies, benefits and Services) Act, 2016, for authenticating identity by
way of Aadhaar authentication.

(After completing all columns 1 to 12,

informant will put date and signature)
Date: D D - M M - Y Y Y Y Signature or (Columns to be filled are over. Now put signature at left)
left thumb mark of the informant

To be filled by the Registrar To be filled by the Registrar

Name Code No.
Registration No. : District
Registration Date: D D - M M - Y Y Y Y
Sub-District
Registration Unit :
Town / Village: Town/Village :
Sub-District:
District: Registration Unit :
Remarks ( if any): Registration No. :
Registration Date: D D - M M - Y Y Y Y

Date of Birth : D D - M M - Y Y Y Y

Sex : Male / Female / Transgender person

Place of Birth: 1. Hospital/Institution 2. House 3. Other place

Name and Signature of the Registrar

Name and Signature of the Registrar
 Instructions for completing the Form 3: STILL BIRTH REPORT

Item Instructions
No.
1 Date, wherever it occurs, is to be provided in dd-mm-yyyy format, where dd is date in two digits, mm
is month in two digits and yyyy is year in four digits Wherever the date is written in words it should
be written in full e.g 01-01-2023 shall be written as First January two thousand twenty three. Use
only 'Arabic numerals' such as 0,1,2,3,4,5,6,7,8,9 for recording dates and other numerical entries.
2 Enter “Male” or “Female” or “Transgender Person”. Do not use abbreviation.

3,4,6 Name, wherever it occurs, is to be provided in the format of [first name] [middle name] [last name]
where full name (not abbreviation) to be written in capital letters and first name is mandatory. There
should be minimum two characters in either [first name] or [middle name] or [last name].

5,6 Address, wherever it occurs, shall contain the name of State or Union Territory, District, Sub-district,
Town or Village, Ward number (in case of town and if available), Locality, House number and PIN
Code.
5 For Place of birth tick the appropriate entry
1. Hospital / Institution
2. House
3. Other place
Give the name and address of the “Hospital / Institution” or the address of the “House” or ‘Other
place” where the birth took place.
7 Town or Village of residence of the mother: Place where the mother usually lives. This can be
different from the place where the delivery occurred. The house address is not required to be
entered.
9 Level of Education – Write one of following—
1.Pre- 6.Class 5 11.Class 10 16. Bachelor / 21. Literate without
Primary Undergraduate formal education

2.Class 1 7.Class 6 12.Class 11 17. PG Diploma 22. Illiterate

3.Class 2 8.Class 7 13.Class 12 18. Master / Post
graduate
4.Class 3 9.Class 8 14.ITI 19. M.Phil
5.Class 4 10.Class 9 15.Diploma / 20. Doctorate & above
Certificate
(Enter the completed level of education e.g. if studied upto class VII but passed only class VI, write
class VI)
12. Cause of foetal death – Write one of following—
1. Bleeding (Hamorrhage) 7. Diabetes in the mother 13. Infection in the mother
Parvovirus B19
2. Problems with Placental 8. Infection in the mother 14. Infection in the mother Q
Coxsackie virus fever
3. Problem with umbilical cord 9. Infection in the mother 15. Infection in the mother
Herpes simplex Rubella (German measles)
4. Pre-eclampsia 10. Infection in the mother 16. Infection in the mother Flu
Leptospirosis
5. Genetic physical defect in 11. Infection in the mother 17. Infection in the mother
the baby Lyme disease Toxoplamosis
6. Liver disorder in the mother 12. Infection in the mother 18. Not stated
(obstestric cholestas) Malaria

Note: The informant must ensure that no item in the Still Birth Report Form is left blank to the extent possible.
 FORM NO. 4
(See rule 7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(Hospital In-patients. Not to be used for still births)
To be sent to Registrar along with Form No. 2 (Death Report)
A copy of this certificate to be provided to the nearest relative of the deceased

Name of the Hospital ……………………………………………………………….

I hereby certify that the person whose particulars are given below died in the hospital in Ward No……………………..

on D D - M M - Y Y Y Y at…………………….A.M. / P.M.
AM
NAME OF DECEASED: First Name Middle
/PM Name Last Name For use of Statistical Office
Sex Age at Death
If 1 year or more, If less than 1 year, age If less than one month, If less than one day, age
age in years in month age in days in hours
1. Male
2. Female
3. Transgender
person

CAUSE OF DEATH Interval between onset

and death approx.
I (a) ……………………………………..
Immediate cause due to (or as a consequences of)
State the disease, injury or complication which
caused death, not the mode of dying such as heart
failure, asthenia, etc.

Antecedent cause (b) ……………………………………..

due to (or as a consequences of)
Morbid conditions, if any, giving rise to the above
cause, stating underlying conditions last

(c) ……………………………………..
II
Other significant conditions contributing to the death ….……………………………………..
but not related to the disease or condition causing it
….……………………………………..

Manner of Death How did the injury occur?

1. Natural 2. Accident 3. Suicide 4. Homicide

5. Pending investigation

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 Attendant certifying the cause of death

Date of verification : D D - M M - Y Y Y Y

SEE REVERSE FOR INSTRUCTIONS

 MEDICAL CERTIFICATE OF CAUSE OF DEATH
Directions for completing the form

Name of deceased : To be provided in the format of [first name] [middle name] [last name] where full name (not abbreviation)
to be written in capital letters and first name is mandatory. There should be minimum two characters in either [first name] or
[middle name] or [last name]. If deceased is an infant, not yet named at time of death, leave blank.

Age : 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.

Cause of Death : This part of the form should always be completed by the attending physician personally.

The certificate of cause of death is divided into two parts, I and II. Part I is again divided into three parts, lines (a) (b)
(c). If a single morbid condition completely explains the deaths, then this will be written on line (a) of Part I, and nothing more
need be written in the rest of Part I or in Part II, for example, smallpox, lobar pneumonia, cardiac beriberi, are sufficient cause of
death and usually nothing more is needed.

Often, however, a number of morbid conditions will have been present at death, and the doctor must then complete
the certificate in the proper manner so that the correct underlying cause will be tabulated. First, enter in Part I(a) the immediate
cause of death. This does not mean the mode of dying, e.g., heart failure, respiratory failure, etc. These terms should not be
appear on the certificate at all since they are modes of dying and not causes of death. Next consider whether the immediate cause
is a complication or delayed result of some other cause. If so, enter the antecedent cause in Part I, line (b). Sometimes there will
be three stages in the course of events leading to death. If so, line (c) will be completed. The underlying cause to be tabulated is
always written in last in Part I.

Morbid conditions or injuries may be present which were not directly related to the train of events causing death but
which contributed in some way to the fatal outcome. Sometimes the doctor finds it difficult to decide, especially for infant
deaths, which of several independent conditions was the primary cause of death; but only one cause can be tabulated, so the
doctor must decide. If the other diseases are not effects of the underlying cause, they are entered in Part II.

Do not write two or more conditions on a single line. Please write the names of the diseases (in full) in the certificates
as legibly as possible to avoid the risk of their being misread.

Onset : Complete the column for interval between onset and death whenever possible, even if very approximately, e.g., “from
birth” “several years”.

Accidental or violent deaths : Both the external cause and the nature of the injury are needed and should be stated. The doctor or
hospital should always be able to describe the injury, stating the part of the body injured, and should give the external cause in
full when this is shown. Example : (a) Hypostatic pneumonia; (b) Fracture of neck of femur; (c) Fall from ladder at home.

Maternal deaths : Be sure to answer the question on pregnancy and delivery. This information is needed for all women of child-
bearing age, even though the pregnancy may have had nothing to do with the death.

Old age or senility : Old age (or senility) should not be given as a cause of death if a more specific cause is known. If old age was
a contributory factor, it should be entered in Part II. Example : (a) Chronic bronchitis, II old age.

Completeness of information : A complete case history is not wanted, but, if the information is available, enough details should
be given to enable the underlying cause to be properly classified.

Example : Anaemia – Give type of anaemia, if known. Neoplasm – Indicate whether benign or malignant, and site, with site of
primary neoplasm, whenever possible, Heart disease – Describe the condition specifically; if congestive heart failure, chronic on
pulmonale, etc., are mentioned, give the antecedent conditions. Tetanus – Describe the antecedent injury, if known. Operation –
State the condition for which the operation was performed. Dysentery – Specify whether bacillary, amoebic, etc., if known.
Complications of pregnancy or delivery – Describe the complication specifically, Tuberculosis – Give organs affected.

Symptomatic statement : Convulsions, diarrhea, fever, ascites, jaundice, debility, etc., are symptoms which may be due to any one
of a number of different conditions. Sometimes nothing more is known, but whenever possible, give the disease which caused the
symptom.

Manner of Death : Deaths not due to external cause should be identified as ‘Natural’. If the cause of death is known, but it is not
known whether it was the result of an accident, suicide or homicide and is subject to further investigation, the cause of death
should invariably be filled in and the manner of death should be shown as ‘Pending investigation’.

In accordance with the provisions of section 10(2) of the Registration of Births and Deaths Act, 1969 (amended in 2023), a
certificate of cause of death shall be given to the Registrar and a copy of the same to the nearest relative of the deceased.
 FORM NO. 4A
(See rule 7)
MEDICAL CERTIFICATE OF CAUSE OF DEATH
(For non-institutional deaths. Not to be used for still births)
(To be given to the person required under the Registration of Births and Deaths Act, 1969 (amended in 2023) to give information concerning the death to Registrar
along with Form No. 2 (Death Report)

I hereby certify that the deceased Shri/Smt./Km……………………………………………………..Son /Wife/ Daughter of ………………………………resident

of ……………………………………….. was under my treatment from ……………………… to ………………………. and he/she died

on D D - M M - Y Y Y Y at…………………….A.M. / P.M.
AM
/PM

NAME OF DECEASED: First Name Middle Name Last Name

Age at Death
For use of Statistical Office
Sex If 1 year or more, If less than 1 year, age If less than one month, If less than one day, age
age in years in month age in days in hours
1. Male
2. Female
3. Transgender
Person

CAUSE OF DEATH Interval between onset

and death approx.
I (a) ……………………………………..
Immediate cause due to (or as a consequences of)
State the disease, injury or complication which
caused death, not the mode of dying such as heart
failure, asthenia, etc.

Antecedent cause (b) ……………………………………..

due to (or as a consequences of)
Morbid conditions, if any, giving rise to the above
cause, stating underlying conditions last

(c) ……………………………………..
II
Other significant conditions contributing to the death ….……………………………………..
but not related to the disease or condition 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 : D D - M M - Y Y Y Y

SEE REVERSE FOR INSTRUCTIONS

 MEDICAL CERTIFICATE OF CAUSE OF DEATH
Directions for completing the form

Name of deceased: To be provided in the following format of [first name] [middle name] [last name] where full name (not
abbreviation) to be written in capital letters and first name is mandatory. There should be minimum two characters in either [first name]
or [middle name] or [last name]. If deceased is an infant, not yet named at time of death, leave blank.

Age : 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.

Cause of Death : This part of the form should always be completed by the attending physician personally.

The certificate of cause of death is divided into two parts, I and II. Part I is again divided into three parts, lines (a) (b) (c). If
a single morbid condition completely explains the deaths, then this will be written on line (a) of Part I, and nothing more need be
written in the rest of Part I or in Part II, for example, smallpox, lobar pneumonia, cardiac beriberi, are sufficient cause of death and
usually nothing more is needed.

Often, however, a number of morbid conditions will have been present at death, and the doctor must then complete the
certificate in the proper manner so that the correct underlying cause will be tabulated. First, enter in Part I(a) the immediate cause of
death. This does not mean the mode of dying, e.g., heart failure, respiratory failure, etc. These terms should not be appear on the
certificate at all since they are modes of dying and not causes of death. Next consider whether the immediate cause is a complication or
delayed result of some other cause. If so, enter the antecedent cause in Part I, line (b). Sometimes there will be three stages in the course
of events leading to death. If so, line (c) will be completed. The underlying cause to be tabulated is always written in last in Part I.

Morbid conditions or injuries may be present which were not directly related to the train of events causing death but which
contributed in some way to the fatal outcome. Sometimes the doctor finds it difficult to decide, especially for infant deaths, which of
several independent conditions was the primary cause of death; but only one cause can be tabulated, so the doctor must decide. If the
other diseases are not effects of the underlying cause, they are entered in Part II.

Do not write two or more conditions on a single line. Please write the names of the diseases (in full) in the certificates as
legibly as possible to avoid the risk of their being misread.

Onset : Complete the column for interval between onset and death whenever possible, even if very approximately, e.g., “from birth”
“several years”.

Accidental or violent deaths : Both the external cause and the nature of the injury are needed and should be stated. The doctor or
hospital should always be able to describe the injury, stating the part of the body injured, and should give the external cause in full
when this is shown. Example : (a) Hypostatic pneumonia; (b) Fracture of neck of femur; (c) Fall from ladder at home.

Maternal deaths : Be sure to answer the question on pregnancy and delivery. This information is needed for all women of child-bearing
age, even though the pregnancy may have had nothing to do with the death.

Old age or senility : Old age (or senility) should not be given as a cause of death if a more specific cause is known. If old age was a
contributory factor, it should be entered in Part II. Example : (a) Chronic bronchitis, II old age.

Completeness of information : A complete case history is not wanted, but, if the information is available, enough details should be given
to enable the underlying cause to be properly classified.

Example : Anaemia – Give type of anaemia, if known. Neoplasm – Indicate whether benign or malignant, and site, with site of primary
neoplasm, whenever possible, Heart disease – Describe the condition specifically; if congestive heart failure, chronic on pulmonale,
etc., are mentioned, give the antecedent conditions. Tetanus – Describe the antecedent injury, if known. Operation – State the condition
for which the operation was performed. Dysentery – Specify whether bacillary, amoebic, etc., if known. Complications of pregnancy or
delivery – Describe the complication specifically, Tuberculosis – Give organs affected.

Symptomatic statement : Convulsions, diarrhea, fever, ascites, jaundice, debility, etc., are symptoms which may be due to any one of a
number of different conditions. Sometimes nothing more is known, but whenever possible, give the disease which caused the symptom.

In accordance with the provisions of section 10(3) of the Registration of Births and Deaths Act, 1969 (amended in 2023), a certificate of
cause of death shall be given to the person required under this Act to give information concerning the death.
 ÑßÑðëð– 5
çðü.No. Form-5
………….. çðܨîðÜ
State
GOVERNMENT OF ....................
Govt.
Emblem ..................विभाग/..(ÑßÙððÂðÑðëð ¸ððÜó ¨îÜÐð÷ ãððâð÷ çÆððÐðóÚðòÐð¨îðÚð ¨îð
ÐððÙð)……….
DEPARTMENT OF.............../. (Name of local body issuing certificate)......

¸ðÐÙð ÑßÙððÂð-Ñðëð
BIRTH CERTIFICATE

(¸ðÐÙð और ÙðöÃÚðô Üò¸ðç¾àó¨îÜÂð ¡òÏðòÐðÚðÙð, 1969 (2023 में संशोधित) ¨îó ÏððÜð 12 / 17 ÃðÆðð….(Üð¸Úð ¨îð
ÐððÙð)..........¸ðÐÙð और ÙðöÃÚðô Üò¸ðç¾àó¨îÜÂð (संशोिन) òÐðÚðÙð, .. (çðüäðð÷òÏðÃð òÐðÚðÙð ¨îð÷ ¡òÏðçðõòµðÃð ò¨î¦ ¸ððÐð÷ ¨îð
ãðæðá)............................¨÷î òÐðÚðÙð 8 / 13 ¨÷î ¡üÃð±ðáÃð ¸ððÜó ò¨îÚðð ±ðÚðð)
(Issued under Section 12 / 17 of the Registration of Births and Deaths Act, 1969 (amended in
2023) and Rule 8 / 13 of the ..... (Name of State)................... Registration of Births and Deaths
(Amendment) Rules............ (Year of notifying the revised rules).

Úðè ÑßÙððòÂðÃð ò¨îÚðð ¸ððÃðð èø कि òÐðÙÐðòâðò®ðÃð çðõµðÐðð ¸ðÐÙð ¨÷î Ùðõâð âð÷®ð çð÷ âðó गई èø ¸ðð÷ ò¨î (çÆððÐðóÚð êð÷ëð)
...................................................... ………...... उप-ò¸ðâðð..............................................................................
ò¸ðâðð .................................................................Üð¸Úð ..................................... ¨÷î Üò¸ðç¾Ü Ùð÷ü £òââðò®ðÃð èø |
This is to certify that the following information has been taken from the original record of birth which is
the register for (local area/local body) .................................................................. of Sub-district
................................ of District .................................of State/Union territory ....................................

ÐððÙð/Name: ..........................................................................................
òâðü±ð/Sex................................................................................................
¸ðÐÙð òÃðòÆð/Date of Birth..........................................................................
¸ðÐÙð çÆððÐð/Place of birth.........................................................................
ÙððÃðð ¨îð ÐððÙð/Name of Mother................................................................
माता का आधार न॰ /Aadhaar No. of Mother: X X X X X X X X

òÑðÃðð ¨îð ÐððÙð/Name of Father ....................................................................

पिता का आधार न॰ /Aadhaar No. of Father: X X X X X X X X

×ðµµð÷ ¨÷î ¸ðÐÙð ¨÷î çðÙðÚð ÙððÃðð òÑðÃðð ¨îð ÑðÃðð / ÙððÃðð òÑðÃðð ¨îð çÆððÚðó ÑðÃðð/
Address of parents at the time of birth of the child : Permanent address of parents:
........................................................... ............................................................
........................................................... ............................................................
........................................................... ............................................................
……………………………………… ……………………………………….
Ñðü¸ðó¨îÜÂð çðü®Úðð/Registration No :............. Ñðü¸ðó¨îÜÂð òÇÐððû¨î/Date of Registration................
ò¾ÑÑðÂðó/Remarks (if any).........................
¸ððÜó ¨îÜÐð÷ ¨îó òÃðòÆð/Date of issue:..............

ÑßðòÏð¨îðÜó ¨÷î èçÃððêðÜ/Signature of the issuing authority

ÑßðòÏð¨îðÜó ¨îð ÑðÃðð/ Address of the issuing authority
Ùðð÷èÜ/Seal

ÑßÃÚð÷¨î ¸ðÐÙð ¦ãðÙð þÙðöÃÚðô ¨îð Ñðü¸ðó¨îÜÂð çðôòÐðòäµðÃð ¨îÜ÷ü/ Ensure registration of every birth and death
 ÑßÑðëð– 6
Form-6
çðü.No.
………….. çðܨîðÜ
GOVERNMENT OF ....................
State
Govt.
Emblem
................विभाग/..(ÑßÙððÂðÑðëð ¸ððÜó ¨îÜÐð÷ ãððâð÷ çÆððÐðóÚðòÐð¨îðÚð ¨îð ÐððÙð)……….
DEPARTMENT OF.............../. (Name of local body issuing certificate)......

ÙðöÃÚðô ÑßÙððÂð Ñðëð

DEATH CERTIFICATE
(¸ðÐÙð और ÙðöÃÚðô Üò¸ðç¾àó¨îÜÂð ¡òÏðòÐðÚðÙð, 1969 (2023 में संशोधित) ¨îó ÏððÜð 12 / 17 ÃðÆðð….(Üð¸Úð ¨îð
ÐððÙð)..........¸ðÐÙð और ÙðöÃÚðô Üò¸ðç¾àó¨îÜÂð (संशोिन) òÐðÚðÙð, .. (çðüäðð÷òÏðÃð òÐðÚðÙð ¨îð÷ ¡òÏðçðõòµðÃð ò¨î¦ ¸ððÐð÷ ¨îð
ãðæðá)............................¨÷î òÐðÚðÙð 8 / 13 ¨÷î ¡üÃð±ðáÃð ¸ððÜó ò¨îÚðð ±ðÚðð)
(Issued under Section 12 / 17 of the Registration of Births and Deaths Act, 1969 (amended in
2023) and Rule 8 / 13 of the ..... (Name of State)................... Registration of Births and Deaths
(Amendment) Rules............ (Year of notifying the revised rules).

Úðè ÑßÙððòÂðÃð ò¨îÚðð ¸ððÃðð èø कि òÐðÙÐðòâðò®ðÃð çðõµðÐðð ÙðöÃÚðô ¨÷î Ùðõâð âð÷®ð çð÷ âðó गई èø ¸ðð÷ ò¨î (çÆððÐðóÚð êð÷ëð)
...................................................... ………...... उप-ò¸ðâðð..............................................................................
ò¸ðâðð .................................................................Üð¸Úð ..................................... ¨÷î Üò¸ðç¾Ü Ùð÷ü £òââðò®ðÃð èø |
This is to certify that the following information has been taken from the original record of death which
is the register for (local area/local body) .................................................................. of Sub-district
................................ of District .................................of State/Union territory ....................................

ÐððÙð/Name: ..................................................................................
ÙðöÃð¨î का आधार न॰ /Aadhaar No. of deceased: X X X X X X X X

òâðü±ð/Sex.........................................................................................
ÙðöÃÚðô ¨îó òÃðòÆð/Date of Death............................................................
ÙðöÃÚðô ¨îð çÆððÐð/Place of Death............................................................
ÙððÃðð ¨îð ÐððÙð/Name of Mother..........................................................
माता का आधार न॰ /Aadhaar No. of Mother: X X X X X X X X

òÑðÃðð ¨îð ÐððÙð/Name of Father……………………………………..…..…..

पिता का आधार न॰ /Aadhaar No. of Father: X X X X X X X X

िपत/ित्नी का नाम/Name of Husband / Wife……………….………..…...…

िपत/ित्नी का आधार न॰/Aadhaar No. of Husband / Wife: X X X X X X X X

ÙðöÃð¨î ¨îð ÙðöÃÚðô ¨÷î çðÙðÚð ¨îð ÑðÃðð/ ÙðöÃð¨î ¨îð çÆððÚðó ÑðÃðð/
Address of the deceased at the time of death: Permanent address of the deceased:
........................................................... ............................................................
........................................................... ............................................................
……………………………………..
Ñðü¸ðó¨îÜÂð çðü®Úðð/Registration No :.............Ñðü¸ðó¨îÜÂð किनांि/Date of Registration................
ò¾ÑÑðÂðó/Remarks (if any).........................
¸ððÜó ¨îÜÐð÷ ¨îó òÃðòÆð/Date of issue:.....
ÑßðòÏð¨îðÜó ¨÷î èçÃððêðÜ/Signature of the issuing authority
ÑßðòÏð¨îðÜó ¨îð ÑðÃðð/ Address of the issuing authority
Ùðð÷èÜ/Seal

ÑßÃÚð÷¨î ¸ðÐÙð ¦ãðÙð þÙðöÃÚðô ¨îð Ñðü¸ðó¨îÜÂð çðôòÐðòäµðÃð ¨îÜ÷ü/ Ensure registration of every birth and death
 FORM NO.7
(See rule 12)
BIRTH REGISTER
Legal information
This part to be added to the Birth Register

To be filled by the informant

1. Date of Birth: D D - M M - Y Y Y Y

2. Sex (Enter “Male” or “Female” or “Transgender person”) :

3. Child’s Details (If not named, leave blank) :-

(a) Name, if any : First Name Middle Name Last Name
(b) Aadhaar No. (if available):

4. Father’s Details:-
(a) Name: First Name Middle Name Last Name
(b)
Aadhaar No. (if available):
(c)
Mobile No:
(d) Email Id:
5. Mother’s Details:-
(a)
Name: First Name Middle Name Last Name
(b)
Aadhaar No. (if available):
(c)
Mobile No:
(d)
Email Id:

6. Address of parents at the time of Birth of the Child: House No:

Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
Permanent address of parents: House No:
7. Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
8. Place of birth (Tick the appropriate entry 1 or 2 or 3 below and give the name and address of the
“Hospital / Institution” or the address of the “House” or ‘Other place” where the birth took place) :
1.Hospital / Institution Name :
2. House 3. Other place Address : House No:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
9. Informant’s Details:
(a) Name: First Name Middle Name Last Name
(b)
Aadhaar No. (if available):
(c)
(d) Mobile No:
Email Id:
(e)
Address : House No:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:

DECLARATION:
I have furnished true information to the best of my knowledge and belief. I am aware of the penalties
under section 23 of the Registration of Births and Deaths Act, 1969 (amended in 2023) for submitting
false information. Also, I give consent, under Aadhaar (Targeted Delivery of Financial and Other
Subsidies, benefits and Services) Act, 2016, for authenticating identity by way of Aadhaar
authentication.
(After completing all columns 1 to 23,
informant will put date and signature)
Date: D D - M M - Y Y Y Y Signature or
left thumb mark of the informant

To be filled by the Registrar

Registration No. :
Registration Date: D D - M M - Y Y Y Y
Registration Unit :
Town / Village:
Sub-District:
District:
Remarks ( if any):

Name and Signature of the Registrar

 FORM NO.8
(See rule 12)
DEATH REGISTER
Legal information
This part to be added to the Death Register
To be filled by the informant
1. Date of Death D D - M M - Y Y Y Y
:Deceased’s Details:-
2.
(a) Name: First Name Middle Name Last Name
Aadhaar No. (if available):
(b)
(c) Date of Birth (if available): D D - M M - Y Y Y Y
(d) Age:

3. Sex (Enter “Male” or “Female” or “Transgender person”) :

Mother’s Details:-
4.
(a) Name: First Name Middle Name Last Name
(b) Aadhaar No. (if available):
(c) Mobile No:
(d) Email Id:

5. Father’s Details:-
(a) Name: First Name Middle Name Last Name
(b) Aadhaar No. (if available):
(c) Mobile No:
(d) Email Id:

6. Spouse’s (husband / wife) Details:-

(a) Name: First Name Middle Name Last Name
(b) Aadhaar No. (if available):
(c) Date of Birth (if available): D D - M M - Y Y Y Y
(d) Age (in completed years):
(e) Mobile No:
(f) Email Id:

7. Address of the deceased at the time of death: House No:

Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:

8. Permanent address of the deceased: House No:

Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
9. Place of death (Tick the appropriate entry 1 or 2 or 3 below and give the name and address of
the “Hospital / Institution” or the address of the “House” or ‘Other place” where the death took
place) :
1.Hospital / Institution Name :
2. House 3. Other place Address : House No:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
10. Informant’s Details:-
(a) Name: First Name Middle Name Last Name
(b) Aadhaar No.(if available):
(c)
Mobile No:
(d) Email Id:
(e) Address : House No.:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
DECLARATION: I have furnished true information to the best of my knowledge and belief. I am
aware of the penalties under section 23 of the Registration of Births and Deaths Act, 1969 (amended in
2023) for submitting false information. Also, I give consent, under Aadhaar (Targeted Delivery of
Financial and Other Subsidies, benefits and Services) Act, 2016, for authenticating identity by way of
Aadhaar authentication.
To the best of my knowledge and information, the detail of Aadhaar of the deceased is not available.

(After completing all columns 1 to 21,

informant will put date and signature)
Date: D D - M M - Y Y Y Y Signature or
left thumb mark of the informant

To be filled by the Registrar

Registration No. :
Registration Date: D D - M M - Y Y Y Y
Registration Unit :
Town / Village: Sub-District: District:
Remarks ( if any):
Cause of death (As per Form 4 / 4A):

Name and Signature of the Registrar

 FORM NO.9
(See rule 12)
STILL BIRTH REGISTER
Legal information
This part to be added to the Still Birth Register

To be filled by the informant

1. Date of Birth : D D - M M - Y Y Y Y

2. Sex (Enter “Male” or “Female” or “Transgender person”) :

3. Father’s Details:-
(a) Name: First Name Middle Name Last Name
(b)
Aadhaar No. (if available):
(c)
Mobile No:
(d)
Email Id:
4.
Mother’s Details:-
(a)
(b) Name: First Name Middle Name Last Name
(c) Aadhaar No. (if available):
(d) Mobile No:
Email Id:

5. Place of birth (Tick the appropriate entry 1 or 2 or 3 below and give the name and address of the “Hospital /
Institution” or the address of the “House” or ‘Other place” where the birth took place) :
1.Hospital / Institution Name :
2. House 3. Other place Address : House No. Locality:
Ward number (in case of town and if available): Town or Village:
Sub-district: District:
State or Union Territory: PIN Code:

6. Informant’s Details:
(a) Name: First Name Middle Name Last Name
(b) Aadhaar No. (if available):
(c) Mobile No:
(d) Email Id:
(e) Address : House No:
Locality: Ward number (in case of town and if available):
Town or Village: Sub-district: District:
State or Union Territory: PIN Code:
DECLARATION:
I have furnished true information to the best of my knowledge and belief. I am aware of the penalties under section 23 of
the Registration of Births and Deaths Act, 1969 (amended in 2023) for submitting false information. Also, I give consent,
under Aadhaar (Targeted Delivery of Financial and Other Subsidies, benefits and Services) Act, 2016, for authenticating
identity by way of Aadhaar authentication.

(After completing all columns 1 to 12,

informant will put date and signature)
Date: D D - M M - Y Y Y Y Signature or
left thumb mark of the informant

To be filled by the Registrar

Registration No. :
Registration Date: D D - M M - Y Y Y Y
Registration Unit :
Town / Village:
Sub-District:
District:
Remarks ( if any):

Name and Signature of the Registrar

 FORM No.10
(See rule 13)

NON-AVAILABILITY CERTIFICATE
(Issued under Section 17 of the Registration of Births & Deaths Act, 1969 (amended in 2023))

This is to certify that a search has been made on the request of

Shri/Smt./Kum………………………..……………………………………………. son/wife/daughter of
…………..…………………………………………….. in the registration records for the year(s)
…………………………. relating to (Local area)…………………………………………………… of
(Sub-District) ……………………………………….……….. of (District) ……………….……………. of
(State) ………………….……………….. and found that the event relating to the birth/death of
………………………………………… son/daughter of ….……………………………… was not
registered.

Date : d d - m m - y y y y
Signature of issuing authority

Seal
 FORM No. 11(See rule 14)

SUMMARY MONTHLY REPORT OF BIRTHS

1. Report for the Month of: _____________ Year :_____________

2. District:

3. Town/ Village:

4. Registration Unit:

5. Number of Births Registered during the month:

Male Female Transgender Person Total*

(1) (2) (3) (1+2+3)

6. Time Gap in Birth registration:

(a) Within Time limit (21 days) of their occurrence:
(b) More than 21 days but within 30 days of their occurrence:
(c) More than 30 days but within one year of their occurrence:
(d) After one year of their occurrence:

Total* (a + b + c + d):

* Total should be equal to the number of statistical part of Birth Report Forms
(Form No.1) attached with this monthly report.

Signature and Name

of the Registrar
Date : d d - m m - y y y y

Submitted to the Chief Registrar/District Registrar

 FORM No. 12 (See rule 14)

SUMMARY MONTHLY REPORT OF DEATHS

1. Report for the Month of: ______________ Year _____________

2. District:

3. Town/ Village:

4. Registration Unit:

5. Details of Deaths Registered during the Month:

Deaths (Including all Infant deaths & Child Infants Deaths (Age less than one year) Child Deaths (Age one year or more but Maternal
Deaths & Maternal Deaths) less than five years) Deaths
Male Female Transgender Total* Male Female Transgender Total Male Female Transgender Total
Person Person Person

6. Time Gap in Death registration:

(a) Within Time limit (21 days) of their occurrence:
(b) More than 21 days but within 30 days of their occurrence:
(c) More than 30 days but within one year of their occurrence:
(d) After one year of their occurrence:

Total* (a + b + c + d):

Note: Infant and Child Deaths & Maternal Deaths should also be included in the
Deaths.

* Total should be equal to the number of statistical part of Death Report

Forms (Form No.2) attached with this monthly report.

Signature and Name

of the Registrar
Date : d d - m m - y y y y

Submitted to the Chief Registrar/District Registrar

 FORM No. 13 (See rule 14)

SUMMARY MONTHLY REPORT OF STILL BIRTHS

1. Report for the Month of: _____________ Year :_____________

2. District:

3. Town/ Village:

4. Registration Unit:

4. Number of Still Births Registered during the month:

Male Female Transgender Person Total*

(1) (2) (3) (1+2+3)

5. Time Gap in Birth registration:

(a) Within Time limit (21 days) of their occurrence:
(b) More than 21 days but within 30 days of their occurrence:
(c) More than 30 days but within one year of their occurrence:
(d) After one year of their occurrence:

Total* (a + b + c + d):

* Total should be equal to the number of statistical part of Still Birth Report
Forms (Form No.1) attached with this monthly report.

Signature and Name

of the Registrar
Date : d d - m m - y y y y

Submitted to the Chief Registrar/District Registrar

 Form No. 14
(See rule 9)
Format of Self-attested document for Delayed Reporting of BIRTH / DEATH under Section
13(2) of the Registration of Births and Deaths Act, 1969 (amended in 2023)
DECLARATION

I…………………………………………………………,son/daughter/wife of
…………….,resident of …………………………………………………………………………. do
hereby declare that:

1. I am the informant for the delayed reporting of Birth / Death of_____(name of child /
deceased)________________________son/daughter/spouse of ………………………………….;
2. He / she was born / died on ___(date of birth / death)_________________________ at (place of
birth / death)…………….;
3. He / she was attended at birth /death by _________________________ who resides
at___________;
4. The reason(s) for the delay in reporting of his / her birth /death are
_______________________________________________________________________________
_______________________________;
5. His / her birth / death certificate is required for the purpose of
________________________________;

DECLARATION:
I, declare that the above information is true and I have not reported the above event to any
Registrar and no birth / death certificate has been issued in this respect, to the best of my
knowledge and belief.

Name and Signature or

thumb mark of the informant

Date D D - M M - Y Y Y Y

Notes:
1. Date, wherever it occurs, is to be provided in dd-mm-yyyy format, where dd is date in two
digits, mm is month in two digits and yyyy is year in four digits Wherever the date is written in
words it should be written in full e.g 01-01-2023 shall be written as First January two thousand
twenty three. Use only 'Arabic numerals' such as 0,1,2,3,4,5,6,7,8,9 for recording dates and other
numerical entries.

2. Name, wherever it occurs, is to be provided in the format of [first name] [middle name] [last
name] where full name (not abbreviation) to be written in capital letters and first name is
mandatory. There should be minimum two characters in either [first name] or [middle name] or
[last name].

3. Address, wherever it occurs, shall contain the name of State or Union Territory, District, Sub-
district, Town or Village, Ward number (in case of town and if available), Locality, House number
and PIN Code.
 Form No. 15
(See rule 16 A)
FORM FOR APPEAL
(To be submitted to District Registrar / Chief Registrar)
(under Section 25(A) of the Registration of Births and Deaths Act, 1969 (amended in 2023))

1. Aggrieved by an action or order of: Registrar / District Registrar or any officer authorized to
act as Registrar / District Registrar (details of office to be provided as below)
State District Sub- Village/Town Locality RU Name of
District ID Registrar / Distt. Registrar or
any officer authorized to act
as Registrar / District
Registrar

2. Account of Event Leading to appeal with date and order no. etc.
(Provide a detailed account of the occurrence, use attachments, if necessary)

DECLARATION:
I have furnished true information to the best of my knowledge and belief.

(Signature of the appellant)

Date D D - M M - Y Y Y Y
Appellant details:
Name Address Aadhaar no. Email Id Mobile No.

----------------------------------------------------------------------------------------------------------------------------- ---
Notes:
1. Please retain a copy of this form for your own records.
2. Appeal, if any, must be submitted to District Registrar / Chief Registrar within a period of
30
days from the date of such action or receipt of such order with which the person is being
aggrieved.
3. Date, wherever it occurs, is to be provided in dd-mm-yyyy format, where dd is date in two
digits, mm is month in two digits and yyyy is year in four digits Wherever the date is
written in words it should be written in full e.g 01-01-2023 shall be written as First
January two thousand twenty three. Use only 'Arabic numerals' such as 0,1,2,3,4,5,6,7,8,9
for recording dates and other numerical entries.
4. Name, wherever it occurs, is to be provided in the format of [first name] [middle name]
[last name] where full name (not abbreviation) to be written in capital letters and first
name is mandatory. There should be minimum two characters in either [first name] or
[middle name] or [last name].
5. Address, wherever it occurs, shall contain the name of State or Union Territory, District,
Sub-district, Town or Village, Ward number (in case of town and if available), Locality,
House number and PIN Code.”.

By order of the Governor

(________________________)
Secretary to the Government of ………………