Death Certificate Form – Fill Out and Use This PDF

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