1. Date of Death

2. Name of the Deceased

3.Permanent Address

4. Name of the father / mother / Husband

5. Age of the Deceased

6. Sex of the Deceased

7. Place of Death

checked > Hospital / Institution	Name
checked > House	Address	{DADDRESS}
checked > Other Place

8. Informant's name

Address

Date

Signature or left thumb mark of the informant

9. Town or Village of Residence of the deceased
Name of Town / Village		Is it a town or village	checked > Town checked > Village
Name of the district		Name of the state
10. Religion		11. Occupation of the Deceased
12. Type Of medical attention received before death	checked > Instiutional checked > Medical attention other than institution checked > No medical attention
13. Was the cause of death medically certfied?	checked >Yes checked > No	14. Name of Disease or Actual Cause of death
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	checked >Yes checked > No	16. If used to habitually smoke for how many years?
17. If used to habitually chew tobacco in any form for how many years?		18. If used to habitually chew areanut in any form (including pan masala) for how many years?
19. If used to habitually drink alchol for how many years?

1. Enter the exact day, month and year of the child was born e.g.1-1-2000

2. Full Name as usually written

3. Enter "Male" or "Female" ; do not use abbrevation

4. If the deceased was over 1 year of age ,give age in completed years.If the deceased was below 1 year of age ,give months,and if below 1 month give age in completed number of days, and if below one day,in hours.

5.Tick the appropriate entry 1,2 or 3 below and give the name of the Hospital / Instituation or the address of the house where the death took place.If other place,give location
e.g. 1. Hospital.

6. 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.

7. Tick the appropriate entry below
e.g. 1. Hindu.

8. If non occupation write 'Nil'

9. Tick the appropriate entry below
e.g. 1. Institutional.

10. Tick the appropriate entry
e.g. 1. Yes

11. For all deaths irrespective of whether medically certified or not

12.Tick the appropriate entry below
e.g. 1. Yes