FORM No. 4 (See Rule 7) (osptaieptens Noto he ss rl ith) To be sen to Rep sang wits Farm No.2 (Death Rep) [Name ofthe Hospital "here cet hat he person whose parce ae given Below ie inthe hopin Ward No, on 3 on ANUP NAME OF DECEASED. Fore of Saal Ofte TET yeararwere, | TFS tan Tye age | le ian one om] Ts Wan ons ay wae fgein yore inmor ‘gsindoye inbooe Tair 2 Femle (CAUSE OF DEATH Intra between one tid death pron L ° Inmet case ete (oraea consequence ‘used deat, aot the mode of dying such as heat fre, ahonin, t Antocden ate o. veto (orasaconsoqence 0), Motbid conditions, if any giving isto the above ° ‘bur not relate tothe disease or eondstion causing it 1. Naru 2 Asvient 3, Side 4, Homie 5 Peadiag vestigation Ir deceased was female, as pregnancy the death asociated wil?” Yes. 2.No yen wae shee alive? 1 Yer 2.0 Date of wtifiation (ob detahsd and hand ver tothe eatve of the dacs) Cn ths SiS Kom SW oF ies this opal on sd expired oa Daxter (Medial SupMEDICAL CERTIFICATE OF CAUSE OF DEATH Directions fr completing the form. [Name of deceased : To be given in all Do mi se ini, ceed ea ints ot ye ned aie of death, we Soa of (S/o) or Daugher of (D0) flowed by names of mote apd fates [Age the deceated war over I year of ae, ve age im completes years. she deceased was Blow {yea of ag, give ag in ‘month anbelow 1 month pve aye completed miber of ay, aml blow one ay, thos {Came of Death This pr the om shoul always be completed by he atlening physician personaly ded oto wo pas, Land Pat is agai ida inte parts es) &) (0) fa sngle morbid eandion completly exis the deaths, hn his wl be writen ine fal of Pa, and ong moe ee be waten inthe est of Pa ori Par Io exams, smallpo, bar pourons, case Beibs ae sien cause of eth ad usually noting rss needa. ‘nen, however, a aumber of morbid condos wil hve boss pete at dash st the doctor ust he complete the eerste he proper numer So thatthe oretundeyeg cus wl abu Fst ce in Pa a) the nee ‘nus of det. This doc et mean the mode of dying, e bear fale, respiratory Tare, ae. These ems shoul ot appear onthe cerifcate at al singe hey ave mode oF dings ot causes of dah, Nex consider whet: themed cause itt compbenion ar deyet rel of ome ober emit Is, eet anscedet xan in Par, ie (b), Sometimes there wl Tether ntages i the coun of event lang to det Ifa, ine) wil be empl. The undeyng ean lobe lated is slays tn in asta Past Morbi enon or injres may be present which were rot crs relat othe tein of evens casing nth ‘which combined in some way 1 the al ouome. Sometnes the doce finds diel to decide expeily fr ina Sets, which of several independ’ condon was the primary cao of deh bt only one eaure canbe tabulated he ‘vor nat decide. Ifthe ter dass ee nor eflcte of he undshiing cat, they ar entered in Ps I Do not write two or mote conden o sgl. ese wrt the ane ofthe ciate (nfl) theceriats ss logit epost vol the sk of hr bong mead ‘Onset = Comps the column fr itr between ont and Gath whenever posible, evn if very appoRimAy, 6 OM et veer yar Accidental or ilet death : Bt he exer ate ad the cure of he iy ae needed ad should be ste, he dtr oF ‘espa shoud always be able to dese te ir, satng the part of the bod Ite, and shuld gs the extemal case ‘all when his isshown. Example (8) Hypostatic pana; (b) Poste of nek 0 fev) Fall rom Tad home atral deaths : Be suet answer the quston on pregnancy an delivery. This nfrmaton neo forall women fc ean ap, eventhough he prepnney may Have had nothing Jo with he dea (0d age or seit: Ol age or senility) should note vena cause of death ia more spi caus is known. IFold age wat ‘conti ico, tna! ened nan I Expl) Chon rons, Io} 93° Completeness of information : A complete case bsory i ot wasted, but, ihe formation i avaiable, enough dete should he pven tu enble the udev case tobe propel lid Example: Anaemia ~ Give type of meni, i knows, Neoplasm ~ Ide wher beng o malignant, ad st, wise of pwimary neler, whenever possible, Hear daeae~ Describe the coon special sungestive heart fala, coisa [mons ee are meron gve he secede anon, Toonur = Deseibe the aneceer ty, kom, Operation = Sate the condon fr hick the operation ws pestrmod Dexotry~ Specify whether acl, amoebs e, f rown Complications of prognancyor deliver = Deb shecopiston specifies, Tubes hve onpane ae ‘Simptamatie samen! : Conlsies, dia, ee, sss, jaundice deli, are syaptons which may be du ay ‘a number of afferent condtons Someries nehing poze is known, bt wacever posible, eve The dea which causal tne yapen, Maneer of Death: Death not et eater tae shod be ef "Nata the aut of eth ie kon, bts [owe wher twas the ero an sci, suicide or hoide and eujetw futher vestigation, the cause of det, should invariably bee in and the anne of death sould be shown a ‘Pending investi’(Fornonsnsi hscby ext hatte dacs ShiSne Km, hte ied on FORM NO. 44 (See Rule 7) eval enths Noto be sed fer il its) ‘sa aang wth Farm No 2 (Desh Repo) sovlwiedaugher of acy see em e ad ‘SAME OF DECEASED. Fara oF Sa OS Se aba a a = Ferme (CAUSE OF DEATH Interval betwoon onset and death apeox 1 @ Irmedite case acto (or ax comaguoncs 3) ‘Ste the disease, injury ot complication which ‘aed dat nt the made uf ing sch a ea ‘aie, athena te, Arscodent oe ® ‘se, sting underlying eas at, ‘namo elated tthe dsesse or conston cussing it (eas ecomseguces a deeasd wa eae, was pegtany the deat asocated wih? yes a thre Yer 2.No (Fo be dewched and handed overt the elative ofthe dees) exif that Shim, RO SW ofS was under my weatment fom and halshe excied on a AMUN, Signature and aldess of Medical PractitionerMEDICAL CERTIFICATE OF CAUSE OF DEATH Directs fr comping the fre. [Name of deceased: Tbe given in ill Dont weil f ces ean nat ot ye ame a tie of det, wrt "Son of {Sia or Daughter of (0) allowed by name of mae abd fer ‘Age: the deceased was over | year of age sive age in completed years the deceased was below I yeu of age, ve age ie ‘mous adit I ath eve agin completed numberof a), a iTblow ene yt buts ‘Case of Death; This pat ofthe frm shoul abmay be completed bythe attending physician personaly ‘The satis ean of death evident wo pars, Iand Pa apn vie imo thes pss, ines) (8) (o). fe single prs condition completely exp the dats, ta ths wil be writen oo ie (a) sf Pa I a noting are eed be won inthe eof Pat To in Pat fo example, salpoe, lobar pacuonia, ear bribe, ae suicienleuse of eat aed usaly pthing nore iseeeed ‘ten, however, a mur of morbid cadtons wi avs hee pret a uth and he dactr mes then empl the erate he proper sneer ota the coectwerying cana wil be auld. Fier in Par) the tod cute ‘of death, This dos not mean the nade of dying. et false, spar fut, cl, Thee ete should ut be appest on the conicate at all since they are snodes of dying and oc causes of death Nex consider waetber the mata cause i 8 ‘complication of debyed res of same ots cts. Iso, eter the aezeeat ease in Po ie (0). Sometines hte wil be Thro tage inthe course of evens ledng fo deh, If ins) wil be compleed, The uadeiing cee 10 be tule ie Mort colons o injuries may be preset which wee not ditty related to the tin of eves cating deth but whieh conuutdin sone way to tefl atcome, Sometimes he dct: Finds it fut odie, espeil int dea, ‘which of several ineepetdent ends was the pir cass of dat; bu ealy ons ease canbe buat othe doctr ast ‘ose Hine othr dssae ar not fei af the mseryng cats they ave cere n Pa TL not write or nore condons on sng ine, lease write the mur ofthe nese (in fl fn the einer ss lel pose to wo the nak of ei beng end. ‘Ont: Compete the column for interval besween ones death whenever posible, even very approximately, “om bint “sever yee” “Actdntl or tole death oth ke external cate andthe at oftheir ae needed and shoal be ate. Te dor ot hospital should alvays be able to deste the injury, ting the part o th ody injure, and shoul ive th extra aus nL we this is shown. Example (9) Hypostic poetmona,(b) Fracture of neck of femur.) Fall or de at hae. Maremal deaths: Be sre to answer te gueston on pregnancy and diver. Ths information is needed fr all women of id= ‘ear as chen hough the propaney may have ad ong odo wh he det, (td age or ent O18 ag (oso shoal ot be ive ax case of death fa ne specific cause is known, od ge wat ‘cout far it Soul be enteed ia Pat I Examol: a) Chon broach, Hol ag6. Completes of nfrmaton:A complete ce isory ina wane, bt ithe informatio eval, nough dete should be vert table te unde aus be propery clase. ample : Anaemia ~ Give type of anaemia, i kxown. Neoplasm ~ neste wheter benign ce elias, thse of ‘ranaty copie, whenever pouibl, Hear dete ~ Desc the conion oily if congestive heat fare, conte ot Fora ear mentioned, give the antcodst codons Tevnar~ Deserve the atocoden jury if awn. Operation = Siu the sondton for which the openion was permsl. Dsentery— Spciy wiser ecilary, amosbe, ee. if known. Complications of pregnancy or delner = Describe he complication spss, Tubrewos = Give onpans feed Symptomatic atment Convulsions, dabes, fever, kes, jas debility, tr enpms which may be dict anyone fa uber of diferent condos Sometimes nothing moe Kaown, but wscevr pea give the diene which ceed the yap