iz:i la- 6
FORM NO. 6
e`R;q izek.k&i=k
DEATH CERTIFICATE
¼ tUe vkSj e`R;q jftLVªhdj.k vf/kfu;e] 1969 dh /kkjk 12@17 vkSj
jktLFkku tUe vkSj e`R;q jftLVªhdj.k fu;e] 2000 ds fu;e 8@13 ds v/khu tkjh fd;k x;k ½
( Issued under Section 12/17 of the Registration of Births and Deaths Act,1969 and Rule 8/13 of the
Rajasthan Registration of Births and Deaths Rules, 2000 )
;g izekf.kr fd;k tkrk gS fd fuEu fyf[kr lwpuk e`R;q ds ewy vfHkys[k ls yh xbZ gS tks fd ¼LFkkuh; {ks=k@LFkkuh; fudk; ½ ----------------------------------
------------------------ rglhy @[k.M---------------------------------------------------------------------------- ftyk ---------------------------------------------------------------------------------------jkT;--@la?k jkT;
{ks=k --------------------------------------------------------------dk jftLVj gSA
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 tahsil / block………………………. of
District………………………………of state / Union territory ……………………………
uke@Name: ………………………………………..............fyax@ Sex ……..............................…………………. e`R;q
dh frfFk@Date of Death …………………..............e`R;q LFkku @Place of death.......................……………… ekrk dk
uke@Name of mother………………………………………………………..............................................
firk@ifr dk uke @ Name of Father/Husband ………………………………...............................................…
e`rd dk e`R;q ds le; dk irk e`rd dk LFkk;h irk
Address of the deceased at the time of death: Permanent address of the deceased:
…………… ………………………………... .................................…………………………..…..
…………………………………………....… .........................................………………………....
………………………………………........… .......................................…………………………..
jftLVªhdj.k la-- @Registration No:. ……… jftLVªhdj.k dh rkjh[k @ Date of Registration …..........................…..
fVIi.kh@Remarks(if any)………………………..................................................................................................
tkjh djus dh rkjh[k @ Date of issue:….................................tkjh djus okys izkf/kdkjh ds gLrk{kj@Signature of the issuing authority
tkjh djus okys izkf/kdkjh dk irk @ Address of the issuing authority
eqgj @Seal
