To
be filled by the informant |
|
12. |
Was the cause of death medically certified?
(Tick the appropriate entry below) : |
|
|
1.
Yes 2.
No |
|
13. |
Name of disease or Actual Cause of Death
:
(For all deaths irrespective of whether medically
certified or not) |
|
14. |
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 :
(Tick the appropriate entry below) |
|
|
1.
Yes 2.
No |
|
15. |
If to habitually smoke -
for how many years? |
|
16. |
If used to habitually chew tobacco in any
form : for how many years? |
|
17. |
If used to habitually chew arecanut
in any form
(Including pan masala) - for how many years ? |
|
18. |
If
used to habitually drink alcohol : for how many
years? |
|
(Columns
to filled are over. Now put signature at left) |