________________________

_____________ _________________/

Nature of Death :

Normal

Still Birth

Dead body found

Applicant Name ____________________________________

____________________________________

Applicant CNIC No. ________________________________

______________________________

Deceased Name ____________________________________

______________________________________/

Deceaseds CNIC No. _______________________________

________________________________/

Relation of applicant with Deceased ____________________

_________________________ /

Religion _________________ Gender __________________

__________________________________________

Fathers Name ______________________________________

___________________________________________

Fathers CNIC No. __________________________________

_____________________________________

Mothers Name_____________________________________

___________________________________________

Mothers CNIC No. _________________________________

____________________________________

Husbands Name ____________________________________

___________________________________________

Husbands CNIC No. ________________________________

____________________________________

Graveyard Name ___________________________________

_________________________________________

Date of Birth _______________________________________

_________________________________________

Date of Death _____________ Date of Burial _____________

___________________________________

Mothers Date of Birth _______________________________

____________________________________

Previous Still Birth __________________________________

____________________________________

Period of Intra-uterine existence _______________________

_________________________________________

Sickness period ____________________________________

_________________________________/

Reason of Death ____________________________________

___________________________________________

Address ___________________________________________

_______________________________________________

__________________________________________________

_________________________________________________

Person name causing Disposal of Body __________________

__________________________________________

Persons CNIC No. __________________________________

________________________________

Doctor / Mid Wifes Name ___________________________

_______________________________________/

THE ENTRY OF THE SAID DATE IS ACCORDING TO THE STATEMENT FURNISHED BY THE INFORMING PERSON/INSTITUTION.
This extract to Mr. /Mrs. ________________________________________ has been issued vide application dated ________________
Rs. __________ regarding fees for the registration/extract has been received vide receipt no. ____________ dated ________________
Book No. ___________ Entry No. __________________ Dated: ____________

Signature of UC Secretary ___________________

Checked by______________ SD________

Birth, Deaths, Marriages and Divorces

(Name & Signatures)

Union Administration _____________(No.___________)

Date of Issuance: ____________________

CRMS No.