DECLARATION BY CLOSE RELATIVE/FAMILY MEMBER FOR

OBTAINING DEATH CERTIFICATE

(To be reported within 21 days of occurrence of the event)

I/We…………………………………....S/o,D/o,Spouse/o……………………..........
R/o (complete address) …………………………………. do hereby solemnly
affirm and declare as under:

1.That the exact and correct date of Death of

Shri/Ms./Smt.……………………………………, Sex Male/Female/Transgender)
son/daughter/spouse of ……………………………… who died at (complete
address)……………………………………...on…………………………………………..

2. That the name of Father of the above deceased is ………………

3. That the name of mother of the above deceased is………………….

4. That the name of spouse of the above deceased is………………….

The above information is true & correct to the best of my knowledge and
belief and nothing has been concealed therein. In case of fraud event, action
may be initiated against me/us as per the provisions laid down under
Registration of Births and Deaths Act, 1969.

Signature of Relative (i.e. informant)

with full name
Relation with deceased:
Mob. No.-
e-mail id(if any):
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