Sample Death Certificate

DHQ Hospital, Sheikhupura

Department : Unit :

Patient Name : XYZ

S/O, D/O, W/O : XYZ
Age : 118 Years 11 Months Sex : Male
Registration Number : 00000
Diagnosis :
Operation/Treatment :
Date of Admission : 01 Jan, 1900 Time of Admission : 12:00 AM
Date of Death : 01 Jan, 1900 Time of Death : 12:00 AM
Cause of Death :
Body Recieved By :
CNIC : 0 0 0 0 0 - 0 0 0 0 0 0 0 - 0
Relation With Deceased : Signatures :

Signature Of M.O :
Name Of M.O :
DHQ Hospital : Sheikhupura
Date : 14 Nov 2018