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FORM NO.2 – DEATH REPORT
Legal Information
This part to be added to the Death Register
To be filled by the informant
1. Date of Death :
(Enter the exact Day, Month and Year the death took place e.g. 01-01-2000)
2. Surname of the Deceased :
Name of the Deceased :
2.a. Surname of the Father / Husband :
(Tick “Father” or “Husband”)
Name of the Father / Husband :
2.b. Surname of the Mother :
Name of the Mother :
3. Sex of the Deceased :
(Enter “Male” / “Female” / “Transgender” : do not use abbreviation)
4. Age of the Deceased in terms of Years / Months / Days / Hours
(Tick “Years” / “Months” / “Days” / “Hours”) :
(If the deceased was over 1 year of age, give age in completed years. If the deceased was below 1 year of age, give age
in months, and if below 1 month give age in completed number of days and if below one day, in hours)
5. Place of Death :
(Tick the appropriate entry 1, 2 or 3 below and give the name of the Hospital / Institution or the address of the house
where the death took place. If other place, given location)
1. Hospital / Institution Name :
2. Residential / Hospital
3. Other Place
Address Line 1 : ---------------------------------------------------------------------
Address Line 2 Hospital / Residential /: ---------------------------------------------------------------------
Address Line 3 Others : ---------------------------------------------------------------------
PIN Code : ---------------------------------------------------------------------
5.a. Address of the Deceased at the time of Death
Address Line 1 : ---------------------------------------------------------------------
Address Line 2 : ---------------------------------------------------------------------
Address Line 3 : ---------------------------------------------------------------------
5.b. Permanent Address of the Deceased
Address Line 1 : ---------------------------------------------------------------------
Address Line 2 : ---------------------------------------------------------------------
Address Line 3 : ---------------------------------------------------------------------
6. Informant’s Name :
Address Line 1 : ---------------------------------------------------------------------
Address Line 2 : ---------------------------------------------------------------------
Address Line 3 : ---------------------------------------------------------------------
(After completing all columns 1 to 17, informant will put date and signature here)
Date :
Signature or the left thumb mark of the informant
To be filled by the Registrar
Registration No : Registration Date :
Registration Unit : District :
Town / Village :
Remarks (if any)
Name and Signature of the Registrar
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Master Codes
Attention at Death Cause of Death
Numeric Names
Numeric Names
Code in English
Code in English
01 Cholera
1 Hospital
02 Typhoid
2 Other Medical Help
03 Food Poisoning
3 No Medical Help
04 Dysentery
4 Others
05 Diarrhoea
5 House
06 T.B
07 Leprosy
Occupation 08 Diphtheria
09 Whooping cough
Numeric Names 10 Tetanus
Code in English 11 Polio machetes
12 Malaria
01 Agriculture 13 Measles
02 Domestic Industry 14 Rabies
03 Industry 15 Cancer
04 Business 16 Diabetes(Sugar)
05 Employed 17 Anaemia
06 Self Employment 18 Meningitis
07 House Wife / Home Maker 19 Heart Attack/Diseases
08 Casual Labour 20 Pneumonia
09 Skilled Labour 21 Influenza
10 Driver 22 Bronchitis and Asthma
11 Agricultural Labour 23 Jaundice
12 Software Engineer 24 Chronic liver diseases
13 Weaver 25 Ulcer of stomach
14 Lorry Driver 26 Appendicitis
15 Doctor 27 Syphilis
16 Labour 28 Abortions
17 Student 29 Complications relating to
18 Photographer pregnancy & child birth
19 Postman 30 Birth Injuries
20 Hotel Server 31 Slow growth of fetus
21 Beggar 32 cerebro vabeular diseases
99 Others 33 Sterility
34 Bites/Strings
35 Accidental Deaths
Religion 36 Accidental Poisoning
(other than food poisoning)
Numeric Names 37 Suicide
Code in English 38 Homicide
1 Hindu 39 Kidney Failure
2 Muslim 40 Paralysis
3 Christian 41 Murder
9 Others 42 Old Age
43 Delivery Death
44 Brain Fever
45 Road Accident
46 Ill Health
47 fire/burns/electricity
48 Sun Stroke
49 Rail Accident
50 HIV
51 Lockup Death
52 Fever
53 Natural (Normal) Death
99 Others
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Statistical Information
This part to be detached and sent for statistical processing
To be filled by the informant
7. Town or Village of Residence of the deceased :
(Place where the deceased actually lived. This can be different from the place where the death occurred. The house
address is not required to be entered.)
a. Name of the Town / Village :
b. Is it a Town or Village
(Tick the appropriate entry below)
1. Town 2. Village
c. Name of District :
d. Name of State :
8. Religion
(Tick the appropriate entry below)
1. Hindu 2. Muslim 3. Christian
4. Any other religion(write name of the religion) :
9. Occupation of the Deceased :
(If no occupation write ‘Nil’)
10. Type of Medical attention received before death :
(Tick the appropriate entry below)
1. Institutional
2. Medical attention other than Institution
3. No Medical attention
To be filled by the Registrar
Name of the District :
Code No. :
Tahsil :
Town / Village :
Registration Unit :
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Remarks column
To be filled by the informant
11. Was the cause of death medically certified? :
(Tick the appropriate entry below)
1. Yes
2. No
12. Name of Decease / Cause of Death :
13. 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 :
1. Yes
2. No
14. If used to habitually smoke – for how many years? :
15. If used to habitually chew tobacco in any form –
for how many years :
16. If used to habitually chew (including pan masala) –
for how many years :
17. If used to habitually drink alcohol – for how many years? :
(Columns to be filled are over. Now put Signature)
Signature of the informant
Registration No : Registration Date :
Date of Death :
Sex : 1. Male 2. Female 3. Transgender
Place of Death : 1. Hospital / Institution 2. House
Name and Signature of the Registrar
