DEATH CERTIFICATE

(Issued under Section 12/17)

            This is to certify that the following information has been taken from the original record of death which is the register for  (Local Area ).................................................. of Tahsil …...................................................................................of District ................................................................. of State .............................................................................

Name -------------------------------------------------------------------------------  

Sex -------------------------------- 

Date of Death  --------------------  

Place of Death  -------------------  

Registration No. ------------------  

Date of Registration --------------  

                                                                                       Signature of Issuing authority

Date ………………………                                                             Seal

No disclosure shall be made of particulars regarding the cause of death as entered in the Register. See provision to Section 17 (I).

  D/P&S – No. 811/28-4-2000 – Medical – 20,000 – C/15-5-2000.