l\

. (Ste Ruic 8)
' MEDICAL CERTIFICATE OF CAUSE OF DEATH
(For Hoepltal ln•P1t11hti. Nol lo bt uaed for 1tlll ,birth&)
To be lent to Regl1ter along with Fonn No. 2 (Death Roport)

Nam~ of lhe Hospital: COIY) 0 j N t\ I 11 0~-p, ·1 t\ ~ . _ ,

I he\eby certify that the person whose particulars are given be\ow died in the hospital in Ward No. cc~ __10
on ). 112 I 2 l al -:( . 06 /\ 1\1 · · Hosp Regn No. · ,,.. r") A ;,," ' -,
f')
I ,,, ...., , -, D
l
NAME OF DECEASED : M EH [ l<' V N
~ IB I F~ruse of
Statistical Office
Sex: Age at Death
,_ ~

If 1 ye~r or morn, If less than 1year, If less than 1day, ' '
If less than 1month,
age 1nyears age In months. . ' age in days age in hours
l ,O'O"o lQ
i
3q ,'-lrs ,· .
'
CAUSE OF DEATH )/,
I .. .,
·.• ' Interval between on111
..._
.. Immediate cause
/

State the disease. injury or complicauon which

(a) ~,\:·~o(J~,~-,\ u
1l- and death cpprox. -
..
-·'
.,

caused death, not the mode of dying suet\ as (due to or_ a co_ n~~cs of) as
heart faihm. asthcma. 'etc. C vi{ ~,- .,,_.....'. ·
Antecedent Cause (b)
Mcxbid conditions, ihny, giving rise to the . . . .
,._
- .- .

above ca~, $tiling underlying c:qndilioiu last due to (or as a ~nsequenc{Ho ..

\·
11 (c) - ,;_

Other significant conditions ~otributing lO lhe

~1--r,.H
death bul not related to the disease or condition . .... .- ~-..... ,:1'·:"/ ""#-'"'. :.·> ..........
causing it . .... \
,. ' ............................- ......................
.. •

(To.be detached and handad over to the relattve of decea$ed)

CoOege c-'.f l· :lltr,:tu
· ';,- . DEATH CERTIFICATION V .. 0.
l' ..

Name of Hospital :co (YI $, J N tv\ II ocp)T /\ L. \ ' \ '

Addre55
·. . \\ ,vQ
1/
"'- I') L\ / (\ J\J I I N (\ 1)1 /\ . :-7A \) ?, <\ . .. (
Certified thal(\/\ l I \ l I< v N f3> I 13, I · · \ , . · ~/0 on-i f\ t(i 11\1 IY) 0 N D/\ L -~
. (P1ll<111t·1 .Reg. No.) (J' . . . , A~ ~~ . . --
Religion Waaadmlttitl1 to thl1 h01p1lal on and expired on A ;84 4 g at -~ · -M:?.'<hq.__,U r-· ~-.-:
due lo :
.
(Y) l) ~ l.. ' M 1. 1o I 1 ) / ,n.. .
. . , . I 2. 2. l..l . '
)_ OJ L -'7 · S '> l"I fY) • ·
I, I .
"T"""'
~\ (:_ M O"<,R) \ L(_( IC. ( Vf\ ) N k K!D vJ N ( /\ ~L o F' 1-\ '}PLR_ , L.N ~ ION
Patient'~ Ad(!rf!5!!. · Signature of Docler : ~
,1 .1 11...- NA t'<fl P()1· J PnQA , Full Name of Doctor : .
pQ • f'J f\ ~ F) P/ )1 I (JI) RA . (lnBloell) {)~ DE~ ~~l\-r-1\ K \J N0 1,1.
PJ - c 1-1 ~"K on H11. N ri o 1-n _~ _7-, 12 .,.. .
A
Oealgnatlon . :MO ·
covnters•~n= · 8 Registration No. (, ."I
s,~nal•Jre of Mr.~.hcal Olficer : _=-/ 2,.1q4 ~ /J;, (v\.( )
ft10,Narnc .:
i)i:;~1;1,::it•~:·\
R~;;ir,\ni!j~~il tJ\)~
_,,. ' '1·:·
. \
 --, r 0 i o\'
~,aine : HR \ di
user" 0\:..

i1;., Patient Sri. No. •

Admission Date :
jN MMiM22Vl,~)5WJ 4S
,,,
'
JNMM/RG:22004516~7 ' :
t{
,:.,, Regisba~Oil No,: FEMALE MEDICINE WARD
tr-. Ward :
t Address
/ :, Munldpalily I Village :
' · ~ Police Station :
State -
Address·tor Commumcatlon :
Married

of Death ....
at ...
 ~i ~= ~iI~ ~a:
: ; :_ . .

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.
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'
 /!...~NO· .:= 1.,_2,o o '{'I"/..IN.f!I 'r . /'4 -/VO - 6
FORM N0.1 BIRTH REPORT
.. r 2 0 ~ o ~tJ2 f!
In the case of multiple births, fill m
~,
BIRTH REPORT
.. ...
~
a separare form for each chlldand
legal Information
~
-0./~" _"offel'-'l'/.a,., Statistical Information
wrfle. 'Twin birth' or 'Triple birth' etc.
~ uthe case may be in the remarks
FORM
NO 1
{_; ~ . column In lhe box below lefl. •
,.
This part to b e addtt_d to the Bir{h:Register ~ ~- c-~ Th'fs part to be detached and sent for ~tllJIJcalprocessing
"
To be filled by the Informant · ''- To be _filled by the Informant To bs fll!Bd by thtl Informant
f. Date ot.Bfrth : (Enter .the exact day, monthJ md rO/12.f l 9. Informant'• name : 15. Mot,,.r'• occupation :
year thechildw~s borne.g . -1--1-2000 ~ brO 4;'~ Address: (If no occupation write 'NirJ.-
(After completing all
Sex ; (Enter "male", "female") I) /t'1 16. Age of the mothe< (in completed
columns 1 to 22,
do not use abbreviation) -- t)L/ T years) at the time of marriage :
informant will put daJe
Name of the child, if any :
(if not named, leave blank)
..
1'. and signature here :)
(If married more than once, age
at ~ marriage my be entered)

Name of the father : ......• -

.. 0)
10. Town pr VIiiage ot Residence of fhe mother : (Place
wh~re the mother usually lives. Thi~ can be dffferent from 17. Age of the mother (m complefed
(Full name as usually written) ff/1NI /V frl.ONLJ,J. ~
, . V)
C
the place where the delivery occurred. The house address - years) at the time of lhis birth :
UID No of father (if any) "' .,
I 1 1 1 1 1 1~ 11111
Name of the mother : ,r,0u - ,
~H
,. _
• Cl.
is not requlreoto be entered.)
a) Name ot Town I VIiiage : 18. Number of children born afwe to
the mother so tar including this /9 c /J .I
(Full name as usually written) ' - r E II'C" n. '" /e3/(3 I ::I
-a:.:: b} Is lt' a town or ylllage: (Trek the appropriate entry child : (Number of Children born LfJ. 1,l..t o/
UIT5No of mother if an - .,~ below) alive to include also those from ·

Address of parents at the time of /Va.ct'4",ia;l:,

•,!2
,,• S!
~ .. 1. Town 2. Vflr.gi,- - ,.._._
19.
eanier marriage (s). if any)
Type ot atte1rtion at delivery : (Tick !he appr~
"-I a..tl..i ~li-
Birth of the Child
/'-0 -
OO • C:
: ,:,8s
c) . Name ot District : ~ below)
..!. ~ d) Name ot State : l U,.::, • '?__;
/J-.5 _ c-1-.a.kd~ .,
:; ~
C:
11 . Religion of the Family : (Trek the appropriate entry below) 2. lnstitutionaJ-Private or Non-Govemment
"!~
1. Hindu ~ 3. Christian
f'_ermane,zt address of parents : :M 3. Doctor, Nurse o< Trained midwife
~- ~ 4. Any other religion : (write name of the religion) 4. Traditional Birth Attendant
,,.. Cl>
• .Q 12~ Father's level of education :
:~
., (Enter lhe compleled level of education
5. Relatives o< others

Place of birth : (Tick the appropriate ·entry 1 or 2 below and ::---,.. e.g. it studied upto class VII but passed 20. Method of Delivery : (Tlck the appropriate entry
only class VI, write class VI) below)
give the name of the Hospit.al I lnstitu_~ n or the address of the ~~ -
=. "" . .. _,;; : ;:/✓ 13.
~
house wh~re the birth took Place) Mother.'• level of education :
~, i;::;.
A -' ,
1. llo!spital/Name: ~ a_<('J ,,,..,v rr,.4,,·I, . ·-,. ·v-'.>- : (Enter the ~ l e d level of education
e,g. if studied upto class VII but passed
Institution e rl , . _. 0- : 3. Forceps Vacuum
only class VI, write class VI)
2. House Address: .:::> ,.:,-., •· ._.,, ~- :.,_• ~
~- -: ,-,>·: p · ~ Father's ·occupation :
21. Birth Weight (in kgs.) (if avaifabje) :
? t} .~<?>'> .. (If no occupation write 'Nil')
~
-,{,"if • T
-Y
_z
•
22. Duration of pregnancy fin weeks) : SL W
Signature of left thumb marfc of the Informant (Columns to be filled are over. Now put signature at left)
To be filled by /he Registrar To be filled by the Registrar
Name Code No. Registration No. : Registration Date :
~ istration No. : Registration Date :
gistration Unit : District : Date of Birth :
lf1 I Village : Tahsil : Sex : 1. Male 2. Female
District :
Jan'.S (if any) : Town I Village : Place of Birth : 1. Hospital / Institution 2 . House
Regislration Unit :
Name and Signature of the Registrar •
Name and Signature of the Registrar
 , \ l V

csc; CHART {ccu1

PATIENT'S NAME: IY.__~ ~ ,&_~~/
DATE
CBG
BEFORE
BED NO:
BREAKFAST
BEFORE
BEFORE D,o--fD
LUNCH REMAR KS ' SIG NATU RE
DINNER
TIME :
10 TIME:l.j,x4op1tt TIME:
)11-- /.31.":"i!k DOSE:
~11J f, i9.-o-±<½ u DOSE : fJ DOSE:

0\ ~ l'3 y ~ /U., TIME : TIME :

TIME :
t-3lMO DOSE :
DOSE :
DOSE:

' 11/ ) <J_ rv1 -.= f O fvra. TIME :

Ti ME : TIME :

~ l 3S''rtf-~ 1DOSE: DOSE:

~
DOSE:
rv / rr1J ~v
TIME : TIME : TIME:
V
DOSE : DOSE: DOSE:

TIME : TIME : Tl ~ E:

DOSE: DOSE : DOSE:

I
TIME : TIME : TIME :

DOSE : DOSE: DOSE:

'

' TIME : TIME: TIME:

I

DOSE: DOSE : DOSE:

i---

I I
L----L--- '"
_,/

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--~- -
""::-:.,
" --.,;·-;\ \ -1;t~iciv1<:V.J~~-:--.-- .
/t,N.jA'.E·sTu, r:s-,~
----br- Name
A--B,£'-~ -G)-An.-. ,- ~ -; ..,- --,- ,--,---y---' -,
of'Patien_t : ~ -- ~
.
,-~ ~ ;_:~-- ·.·:, ;-'16=--~!g?t/V'9JS-i&'_rl1,
' ~' ---.-T-_P:
-y 0 M9b{M ~ o'!:
- "'- - 0:
. - -
~ "'l -~
hi 11
' . JiJE
-~ ,.ir;;/~•·
1

_-;-·' : R;) ' I :A~e:} ~ 6yr. fe"~fr'.

N "J.J AIQ, 1 I I J f .J , ...__ ..
M/ .Yi 1 Body Weight:
I

K
l .
Height:
'
!. ' - ~m- _BfW - -,:.~ -:,, .
r~sPl{ege of_Medlci ne an~TNM !§_{p~ ; ~ ~ nl ENi. t-:-Sfi,~,~f..iY,.{-;S~JBfl~wLL .'? s _ Gynaecology -I -Orthopaedics I Eye- /
Depart~ent: Pain : .J-
t,West Bengal U'!l✓erilty of-l:le~·1t lf~~ien'>~~;}~ ;S~rg~ry:_.; · ien~1 1-:.-Eiecthl; ..,!. : ]Hb; _! ..... .,..._ . gm/di ABJ:: - ~--- PAC-No~ , 1 ..
- ~ ' ' - - "'!._ ""' _:_l ; ,- ' • , J -

ICheck fist: 7o;,;ent 2. PAC 3. ~lqo~ lf~~pohent A~il~bilify:~-::~ ~ -~. -:.. ~ - -~ ~:i'c~ Arranged (SOS):
'Diagnosis: . ~ . U , ~ c CVlt -'c ~ . J:.·~~,. .. do • ~- "'r,;;-
7
'/!NPO: Solid- hr, Liquid~ hr
IProposed Surgical Procedure,· ·' £.,__u,_ C-! .. : ~- -'!;:. .,, ·••.-r ;;:,;.a /Proposed duration of Surgery :
!Surgical Procedure-Performed r; , LU c~ • = "" ' '·".:- - /Actual duration of Sufiery :
Peripheral Venous cannulation:
1 /Anaesthesia lndu¢on time :
!Arterial Cannulation /Surgery Start time ~ :
1
Central Venous Catheter: !Surgery End time :
/J>c:,sitioning of Patient <- ;: t _,._ -"- !Anaesthesia Reversal time
'Pressure point protection (If Any):
Surgical"Team I Anaesthesia Team Nursing Staff OT Tech nlcia n/Assistant
JU·~-
fU.· ~~1:&f-M·:-Jo<JBJ~~J..
Eye Protection .-·
911 · A·' -J~ MA'o.--- Group D Staff Tape / Ointment / ~ ng / OPen
,v Fluid Calculation: .LJJt n Ryle's Tube I F.Catheter:
Preinduction: GCS_:a"'(!:'fPulse: f21(/min , BP:2tJr, ,o:, mmHg
',ir
, Resp Rate:/' O/min, So02 (In Room Air): / 00 % , Temperat ure: kjt:)( , A-4 C'.
4naesthesia Administered: ·
~ eral Anaesthesia/ TIVA / MAC 1 SAB /Epidural/ CSE Peripheral Nerve Block/ LA
~ sition:
1
".'.'::m"' Position: / Position:
'O);Vgenation: :10 . IV Space: / Block Type:
'•ngoscope/FOB: Needle Type & Size: Approach:
:ie / Stylet: W . Catheter Fixed At: Needle Type/ Size:
rype/Si~: -:J--f; ~W fZ;l,d-1,,f, No. of Attempt: ~Needle length:
I Qµn/ Trans Tracheaf:V
~ttempt: J.
o/·
No. of Anaesthestist:
Drugs Injected
Any Aid Guided:
Drug Used:

____ __
naesthestlst":7.
Volumn of Drug:

~
?dAt 2.,..-t.-. _,,_
~
Adequate /
__.;..
Inadequate Eficacy of Block: Adequate /

-
ck: ,-,0 Inadequate
<' e/Si_:e): Awake/Sedated:
Awake/Sedated:
\
t, ••
~
Any): ,-.,.J
Loi· -

Spontaneous I cci.oir61ted
c7
GA Suplimentation:
GA Suplimentation:

Oxygen Support (If Needed) :

~
Oxygen Support (If Needed):

--
 I
-·1.
- I
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~ ,.,....................,....'~......,:.

~
Time Line

I
.=:0 tt
~~; ~ 1 ~ I ~[;? ~ 111
. . 1H $¥i4ffH I, 1111111'· 11 •1 I, I I I I,III
I l
th
' ""'"''""" Utt'" ,, ' " , ..
IAnyO er Complaln(lfany) :

I 'c ~-TIEt1JfU 1111111111 ·1 .I 111 , 11111111111 ·111111

lntraoperaflve~t,,onlt@!l_g_
Shifted to : CN
_..___,_., Shifted with support (If any):

• e.
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f.,4 •·9w ~
IJ--'.

dv'lce
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- (v,= C t.L: Ns- &~
... ~ :8~~ q;-
tth "1~~ · ~~
(2,

flP
V
0-<::: ~
~ ,J ~
A
(l,

"~ ~ r:;:-(, Uf
1.!• ,,
- ~ f ~o c.:,"~
Pulse • Ll..111 1
,? ~ 'i
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~"~
0~ ~ (l, ~' .
(j s ..l

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IV lnfuelon I Tran1fu1lon_ TotaJ

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9-
•
ANN EXURE - 0
Conti nuation Sheet
Office of the Medical Superintendent El
COLLEGE OF M EDICINE & JNM HOSPITAL ~
WBUHS , KALYAN I, NAD IA
Na rn e :
Unit :
ti B. No. :

Date
I Diet T
Ward : <!..c..,,(J •
Treatment
. • l~ltll~ '. ('.- . f~ - 0() - o>J.,,\l'z
~~ ~
~ ""} • '.l'.\f(::c I'\,;·. RL c_ i '. , ) 0 b . ~
(_ L._ S°'1_....,-,61< . tof\"!\t_WA.t__ '1\,Wbto,I,• ~ .(.. IK~ Vi'\~ " ~ I
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 "',"'"::'._"'t,~~1."J:~"i'.i~.,....a-s
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ANNEXURE· D
Continuation Sheet
Office of the Medical Superintendent
COLLEGE OF MEDICINE & JNM HOSPITAL
l
WBUHS , KALYANI , NADIA. l

Name Unit :

B. No.: Ward:

I
Date Diet Treatment

· 0 C)_ 'W VV) f'll ~'fV('t) \- ~ \".

.' , I

~ ~ ,.,..;.rnl__ ""'~ ~ .:- L c_ vi\ .~ .

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'

I DEPAR~~tOF HEALTH AND FAMILY WELFARE.,··

tiOvtRNMENT OF WEST BENGAL
f \
'

/
atient's Name :
·.
RECORD OFDEATH

Co llege of..fvledicine t,,'J~ M .-H:,o::_si:_pi'..':La~l'.:.:.W

KIU:rnWrN1IDIA
lf'H .o:n-·;dB2133 B6bx :
~B~
U'..:l-~
IS:'.._.._ _ _--::_ _ _ _ __ _ __
Age : Yrs.
1
-;

Months Days
35 · 0 0
M EHERUN BIBI Pe male
Patient Srt. No. : Registration No.:
JNMMl}?AJ,QQQ58448

De.ts confumed by be on
Enter only one cause per line for (a), (b) and (c) Approximate
interval between
CAUSE OF DEATH onset and death
Disease or condition directly leading , , (a) [ ICDIO Code :.
to death* due to (or as a,consequence1of) .1 / ,
.I I • \ \

Antecedent causes (b) [ ICDIO Cod~ :......:.\: .. \.i..~.'........_\ ..........:..:........\. .,..... ,.\.'.. .................... ..
" -
\ -
Morbtd conditions, If any giving ~ctue to (or as,a consequence of)
\I ·--· ,1-
rise to the above cause, starting . - \

the underlying con'dttierrlast ' (c) [ ICDIO Code :•. ............................. ]..... ..... ............................................ ..
- I \ ~✓ I - • . \ \' .. '
U -l !· '\ ~
Other significant conditions contributing to the .... . .... . . . . .... . . ... . .. .. . . .. . . . ........ .. ... . ........... .,... . .. ... ... . . . .
► death but not related to the disease or condition - .,
' 1 ,
I I

~
:°'~il~gdi~ not m~ an 'the mod~iof dying e.g. heart f~ii~;~,·~~th·~~i~: l~t~'. it.1~.~~1~~ ih~ ·di~~~~~·. ·i~j~~· ~~ ~;,;~ji~ti~~·~hi~h ·~~~~d ·d~~th··
~
' Recordjof Birth '' ~ \I

1.
Father's Education : Occupation : ..•...:-::-:: ...::-: .... ... ................................,....................._........., ......
- I'·

1
Occupation : .. .. ...... ..................
\ '\ \\·

\........... ~ge of Mother At The TI me Of Delivery :.. ....._

~
......_

~=· . .. . . . .....:.:~,·· . ·,; .· ·.-

\

j
Mother's Education :.
--.,! ~ \ ,, ' '" '
- '
Type of birth : Single / Multiple Order of pr~rancy ...... .... ........... .................. Antenatal care received-Yes./No
,:- Gestatioh\perlod
1
' ~) J I t\laemoglobln perceAtage
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Actual No. ot birth . in Weeks ......... ......... .. ........ .. ..... :................... prior to confinement '
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RAFDER
n:4 .00 .00 07
ro : JO BIBI
AC C,No .:
sample No.:67 8 c ; Female.

~C ID / BASE 37 .0°C tl;Js Profile. ( Level - 1)

pH 7 .44
PCO2 l 25 rrrrt,g
PO2 109 rrrrt,g
BE -6.4 mnol/L
tCO2 17 .3 mno l/L
HCO3 16. 5 111no I /L
stHCO3 19.2 mnol/L ,nt in Changing lie presentation .

ELECTROLYTES md reg.lilar ca:rdiac pulsation - 151

Na+ 145 mnol /L -4.
K+ 4.0 mnol /L
ca++ l o. 97 mno I /L
1
r~ t~~~Mietirf :·~ .·::"i;~····; r·······,, ·········
%1:.fi'.'.'.(~;t~,<;"~,✓-:'{•q, -1?,.~i - . . ,
~p11q3%!{~~;#:;:~:~.:<,<; :,:-:i~_$-<-~;-~~-~/ -· _.~,<............................-.·. ·_.· --·..
HEMOG LOBIN/OXYGEN STATUS iyeeks, 1 7[fa;ys
t Hb l 9.4 g/d L
SO2 97 % "' ts'~~~c
Hct (c ) 28 %
;H ERED PARAMETERS
DOB 0
remp 37 .o c
sex ?
Hb rype Adult
MCHC 33. 3 %
FlO2 0. 21
RO 0. 84
P50 26. 7 m'rt-lg "1aturi.ty grade 'I'
3arometer:756. 7 m'rt-\g
)perator 10:
5/N:15362 LOT:218411 1est pocket measures: 39.9 mm.

(Ref .Lim)
pH 7. 20 - 7 .60
PCO2 30 - 50 ITTl1,g
PO2 70 - 700 IITTHg
Na+ 135 - 145 mno I /L 11aturity around 22· weeks 6 ·da)
K+ 3 .5 - 5 .1 mno I /L
Ca++ 1 .12 - 1 .32 mnoI /L
tHb 12.0 - 17 .0 g/dl
SO2 90 - 100 %
l~FSSAGES rade-1 maturity.
Pt )2 under 30 (Ref .L irn)
Cc..'-+ under 1 .1 2 (Ref . L i rn) r e TIFA protocol preferably~at 1~..tQ,&.
r.Hb under 12 .o (Ref.Lim)
Reminder: HbCa I n, ,,...
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