{AJAXCONTENT}
    Complete - Death Report
  Legal Information
1)  Date of Death : {DOD}
2)  Name of the Deceased : {NOD}
3)  Permanent Address : {DODADDRESS}
4)  Name of the father / mother / Husband : {NAMERELTION}
5)  Age of the Deceased : {AGE}
6)  Sex of the Deceased : {SEX}
7)  Place of Death : {POD}
8)  Informant's name : {INFONAME}
     Address : {ADDRESS}
{DDATE}
Date 		{INFOSIGNORTHUMB}
Signature or left thumb mark of the informant
Registration No & Unit   
Registration Date
Town / Village
Taluk
District
Remarks (if any)
  
Name and signature of the Registrar

   Statistical Information
9)  Town or Village of Residence of the deceased
Name of Town / Village : {VILLGETOWN}
Is it a town or village? : {DRES}
Name of the district : {DISTIRICT}
Name of the state : {STATE}
10)  Religion : {RELIGION}
11)  Occupation of the Deceased : {OCCUPATION}
12)  Type of medical attention received before death : {MERDATTENTION} {MERDATTENTION1} {MERDATTENTION2}
13)  Was the cause of death medically certfied? : {MEDICALLYCERTIFIED}
14)  Name of Disease or Actual Cause of death : {NAMEACTUALCAUSEDEATH}
15)  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 : {DELIVERYENDPREGNANT}
16)  If used to habitually smoke for how many years? : {HABITSMOK}
17)  If used to habitually chew tobacco in any form for how many years? : {HABITCHEWTOBACCO}
18)  If used to habitually chew areanut in any form (including pan masala) for how many years? : {HABITPANMASALA}
19)  If used to habitually drink alchol for how many years? : {DRINKALCOHLYEAR}

Approve       Reject