Form No. 2 DEATH REPORT Death Application No : 1089748 Form No.

Legal information DEATH REPORT

Statistical information

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 To be filled by the informant

1. Date of Death: 20/02/2021 11. Town or Village of 15. Was the cause of death medically N
Residence of the certified?:
Deceased :
2. Name of the Deceased: ‫ٶڤڗڞڬښڡ‬HARESHBHAI a) Name of State: GUJARAT 16. Name of Disease or Actual Cause of Unknown
Death:
3. Sex of the deceased: Male b) Name of District: Banas Kantha 17. In case this is a female death, did No
the death occur while pregnant, at
the time of delivery or within 6
weeks after the end of pregnancy:
4. Name of Mother: F\hWZpWGAMANBEN c) Name of Taluka: Vadgam If Yes then level of education of the
Deceased:
5. Name of Father/Husband : SEDHABHAI BHIKHABHAI CHAUDHARY - RUPAVAT / d) Name of Town or Edrana 18. If used to habitually smoke-for how No / 0 yrs
dpVh[h9[jEh[h:ItV^ŽĮXhaN Village: many years?

6. Age of the deceased: 43 Years e) Is it a Town or Village 19. If used to habitually chew tobacco No / 0 yrs
Village : in any form-for how many years?
7. Address of the deceased ?U^hRhEDRANA 12. Religion : Hindu 20. If used to habitually chew arecanut No / 0 yrs
at the time of death: in any form(including pan masala)-
for how many years?
8. Permanent address of the ?U^hRhEDRANA 13. Occupation of the Not-Stated 21. If used to habitually drink alcohol - No / 0 yrs
deceased: Deceased : : for how many years? :
9. Place of death: EDRANA 14. Type of medical No medical attention Death Application No : 1089748
attention received
before death:
Address: EDRANA

10. Informant's name: PACHANBHAI SEDHABHAI RUPAVAT

Address: EDRANA

Death Application No : 1089748

Date : _______________ 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: Registration Date : State : Gujarat Code No. Registration No:
Registration Unit: EDRANA District : Banas Kantha Registration Date:

Town/Village: Edrana Tahsil: Vadgam Date of Death : 20/02/2021

District: Banas Kantha Town/Village: Edrana Sex: Male
Remarks: Registration Unit: EDRANA Place of Death: EDRANA

Name and Signature of the Registrar Name and Signature of the Registrar

Courtesy : National Informatics Center Print Time :-02/24/2021 11:22:10 AM