GOVERNMENT OF KHYBER PAKHTUNKHWA

LOCAL GOVERNMENT, ELECTIONS AND RURAL DEVELOPMENT DEPARTMENT

Form-D
APPLICATION FORM FOR DEATH REGISTRATION )‫(درخواست فارم براۓ اندراج فوتگی‬
[see rules 4(c), 23(1), 24, 27 (1) (a) & (b) and (2)]

Name of Deceased:______________________________________________________________________________:‫متوفی کا نام‬

CNIC Number of Deceased (if applicable) - -
Residential address of the deceased:_______________________________________________________________:‫پتہ‬
Date of birth of the deceased:_______/______/__________. Religion of deceased:________________________:‫مذہب‬
Occupation of the deceased:________________________:‫متوفی کا پیشہ‬
، ‫______ دن‬،‫______ماہ‬، ‫______ سال‬:‫متوفی کا عمر‬
Name of deceased’s spouse:____________________________________________________:‫بیوی کا نام‬/‫متوفی کے شوہر‬
CNIC No. of deceased’s spouse: - -

Name of deceased’s father:___________________________________________________________:‫متوفی کے والدکا نام‬

CNIC No. of deceased’s father:
- -
Name of deceased’s mother:________________________________________________________:‫متوفی کے والدہ کا نام‬
CNIC No. of deceased’s mother:
- -
Name of deceased’s guardian (individual or organization) in the case of destitute / orphan / homeless person
(a) CNIC No. of deceased’s guardian - -
or
(b) Registration No. of organization:_______________________________.:‫تنظیم کا رجسٹریشن نمبر‬
Gender of deceased Male Female Transgender :‫متوفی کا جنس‬ ‫تفصیل وجہ‬
(‫)وجہ فوتگی‬ Natural death Natural Murder Accident
_________:‫فوتگی‬
Cause of death: Calamity ___________
Serious illness Suicide Custodial Unknown
Death factors
:
Date of Death:____/_____/_______. Date of Burial:____/____/______. Place of Death:_________________________:‫جاۓ وفات‬
Name of Graveyard:_________________________. Duration of deceased’s illness prior to death:_______________________.
Name of Doctor who certified the death:______________________________________:‫ڈاکٹرکا نام جس نے موت کی تصدیق کی ہو‬
Registration No. of Doctor who certified the death:________________________ .:)‫ڈاکٹرکارجسٹریشن نمبر(جس نے موت کی تصدیق کی ہو‬
Name of Burrier or Close Relative:_______________________________________________:‫تدفین کنندہ یا قریبی رشتہ دارکا نام‬
CNIC Number of the Burrier/ Close Relative:
- -
Relation:___________________ :‫متوفی سے رشتہ‬

Name of Applicant:_____________________________________________________________________:‫درخواست دہندہ کا نام‬

CNIC Number of the Applicant: - -
Relation:___________________ :‫سے رشتہ‬ ‫متوفی‬
Address of the Applicant:_________________________________________________________ :‫درخواست دہندہ کا پتہ‬
Contact # of Applicant: ________________________: ‫رابطہ نمبر‬
DECLARATION
I hereby solemnly affirm on oath that all information given hereinabove is correct to the best of my knowledge, information and belief.
The death of the concerned person has not been registered anywhere else in Pakistan. Therefore, the death of the deceased may please be
registered.

Applicant’s signature / Thumb impression: ___________________________________________ ) ‫( درخواست دہندہ کا دستخط یا نشان انگوٹھا‬

FOR OFFICIAL USE ONLY

Date_____/____/_______. CBR No. issued _________________________________

SECRETARY
Village/Neighbourhood Council _________________________
(Name, Signature and Stamp)
 GOVERNMENT OF KHYBER PAKHTUNKHWA
LOCAL GOVERNMENT, ELECTIONS AND RURAL DEVELOPMENT DEPARTMENT

AFFIDAVIT/ VERIFICATION
(For Death Certificate)
[see rule 27 (2)(3)]

We hereby solemnly affirm on oath that____________________________________________________ S/O or D/O

__________________________________________________ CNIC Number __________________________________has
been died on _______/______/_________, and is buried on ___/____/______ in _______________________ (graveyard)
________________________________________Mohallah___________________________________________________
Village/Neighbourhood Council__________________________________________P.O_____________________ Tehsil
_______________________District_______________. We personally know the deceased, his family and the
person/applicant who applied for registration and issuance of the death certificate of the deceased with CNIC No.
_______________________________ in Village/Neighbourhood Council _________________________ He / she is a
citizen of Pakistan and we shall be responsible in case the said person is found to be fraud or foreigner upon investigation of
any government agency.
Witness No.1 Witness No.2
Signature/Thumb impression: Signature/Thumb impression::

Name: Name:

Father / Husband’s name: Father / Husband’s name:

CNIC No. CNIC No.

Contact No. Contact No.

VERIFICATION & APPROVAL BY THE CHAIRMAN VILLAGE/NEIGHBOURHOOD COUNCIL

(for Death Certificate)
The information provided by the applicant with the above statement of witnesses has been verified through
enquiry and found correct to the best of my knowledge and belief.
The case is approved for registration and issuance of Death Certificate.

(Signature and Stamp)

CHAIRMAN
Village/Neighbourhood Council ___________

RECIEPT

Serial No.___________ Date of Registration: ____/___/_______.

Name of the Deceased:__________________________________________________ Father’s Name:_______________________________

Mother’s Name:______________________________ Address:__________________________________________ Fee:________________

SECRETARY
Village/Neighbourhood Council _________________________
(Name, Signature and Stamp)