THE LAKSHADWEEP GAZETTE EXTRAORDINARY

“ FORM NO.1

(See rule 5)

BIRTH REPORT

Legal information

[SEE REVERSE FOR INSTRUCTIONS]

FORM NO.1

(See rule 5)

BIRTH REPORT

Statistical information

[SEE REVERSE FOR INSTRUCTIONS]

This part to be added to the Birth Register

This part to be detached and sent for statistical processing

(a)

(b)

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

To be filled by the informant

Date of Birth :

Sex (Enter “Male” or “Female” or “Transgender person”) :

Child’s Details (If not named, leave blank) :-

Name, if any :

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Father’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Mother’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Address of parents at the time of Birth of the Child: House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Permanent address of parents: House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Place of birth (Tick the appropriate entry 1 or 2 or 3 below and give the name and address of

the “Hospital / Institution” or the address of the “House” or ‘Other place” where the birth took

place) :

1.Hospital / Institution Name :

2. House 3. Other place Address : House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

10.

11.

(a)

(b)

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

To be filled by the informant

Town or Village of Residence of the mother (Place

where the mother usually lives. This can be different

from the place where the delivery occurred. Tick

appropriate entry “Town” or “Village” and write its

name):

Town or Village: Sub-district:

District: State or Union Territory:

PIN Code:

For Religion [Enter appropriate religion “Hindu” or

Muslim” or “Christian” or “Sikh” or “Buddhist” or “Jain” or

“Other (Please specify)”]

Religion of Father:

Religion of Mother:

Father’s level of education:

Mother’s level of education:

Father’s Occupation:

Mother’s Occupation:

Age of the mother (in completed years) at the time

of marriage (If married more than once, age at first

marriage is to be written):

Age of the mother (in completed years) at the time

of this birth :

Number of children born alive to the mother so far

including this child (Number of children born alive to

include also those from earlier marriage(s), if any) :

Type of attention at delivery (Tick the appropriate

entry below):

Institutional-Government

Institutional – Private or Non-Government

Doctor, Nurse or Trained Midwife

Traditional Birth Attendant

Relatives or others

Method of Delivery (Tick the appropriate entry below):

Natural

Caesarean

Forceps/Vacuum

Birth Weight (in kgs.) (if available) :

Duration of pregnancy (in weeks) :

(In the case of multiple births, fill in a separate form

for each child and write 'Twin birth' or 'Triple birth'

etc., as the case may be, in the remarks column in

the box below left.)

(a)

(b)

(c)

(d)

(e)

Informant’s Details:

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Address : House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

DECLARATION:

I have furnished true information to the best of my knowledge and belief. I am aware of the penalties

under section 23 of the Registration of Births and Deaths Act, 1969 (amended in 2023) for submitting

false information. Also, I give consent, under Aadhaar (Targeted Delivery of Financial and Other

Subsidies, benefits and Services) Act, 2016, for authenticating identity by way of Aadhaar

authentication.

(After completing all columns 1 to 22,

informant will put date and signature)

Date:

M M

Signature or

left thumb mark of the informant

(Columns to be filled are over. Now put signature at left)

To be filled by the Registrar

Registration No. :

Registration Date:

Registration Unit :

Town / Village:

Sub-District:

District:

Remarks ( if any):

Name and Signature of the Registrar

Name

Code No.

District

Sub-District

Town/Village :

Registration Unit :

Registration No. :

Registration Date:

Date of Birth :

Sex : Male / Female / Transgender person

Place of Birth: 1. Hospital/Institution 2. House 3. Other

place

Name and Signature of the Registrar

To be detached and sent for statistical processing

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

Instructions for completing the Form 1: BIRTH REPORT

Item No.

Instructions

Date, wherever it occurs, is to be provided in dd-mm-yyyy format, where dd is date in two digits, mm

is month in two digits and yyyy is year in four digits. Wherever the date is written in words it should

be written in full e.g 01-01-2023 shall be written as First January two thousand twenty three. Use

only 'Arabic numerals' such as 0,1,2,3,4,5,6,7,8,9 for recording dates and other numerical entries.

Enter “Male” or “Female” or “Transgender Person”. Do not use abbreviation.

3,4,5,9

Name, wherever it occurs, is to be provided in the format of [first name] [middle name] [last name]

where full name (not abbreviation) to be written in capital letters and first name is mandatory. There

should be minimum two characters in either [first name] or [middle name] or [last name]. If child is

not named, leave blank.

Birth can be registered without name of the child. However, name of child can be inserted, free of

charge, within 12 months of registration (Refer Rule 10 of State Rules).

6,7,8,9

Address, wherever it occurs, shall contain the name of State or Union Territory, District, Sub-district,

Town or Village, Ward number (in case of town and if available), Locality, House number and PIN

Code.

Tick the appropriate entry for place of birth

1. Hospital / Institution

2. House

3. Other place

Give the name and address of the “Hospital / Institution” or the address of the “House” or ‘Other

place” where the birth took place.

Town or Village of residence of the mother: Place where the mother usually lives. This can be

different from the place where the delivery occurred. The house address is not required to be

entered.

12,13

Level of Education – Write one of following—

1.Pre-

Primary

6.Class 5

11.Class 10

16.

Bachelor

Undergraduate

21. Literate without

formal education

2.Class 1

7.Class 6

12.Class 11

17. PG Diploma

22. Illiterate

3.Class 2

8.Class 7

13.Class 12

18.

Master

Post

graduate

4.Class 3

9.Class 8

14.ITI

19. M.Phil

5.Class 4

10.Class 9

15.Diploma

Certificate

20. Doctorate & above

(Enter the completed level of education e.g. if studied upto class VII but passed only class VI, write

class VI)

14, 15

Occupation - Write one of following—

1. Cultivator

2. Agriculture Labourer

3. Daily Wages Earner(Other than Agriculture Labourer)

4. Single/Family Worker/Self Employed

5. Employer

6. Government Employee

7. Private Employee(Other than Domestic Helper)

8. Domestic Helper

9. Non-Worker

Note: The informant must ensure that no item in the Birth Report Form is left blank to the extent possible.

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

FORM NO.1-A ( Legal information) (See rule 5)

BIRTH REPORT FOR ADOPTED CHILD

[SEE REVERSE FOR INSTRUCTIONS]

This part to be added to the Birth Register

FORM NO.1-A Statistical information (See rule 5)

BIRTH REPORT FOR ADOPTED CHILD

[SEE REVERSE FOR INSTRUCTIONS]

This part to be detached and sent for statistical processing

1*.

2*.

(a)

(b)

4*.

(a)

(b)

(c)

(d)

5*.

(a)

(b)

(c)

(d)

(a)

(b)

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

10.

11*.

12.

13.

(a)

(b)

(c)

(d)

(e)

To be filled by the informant

Date of Birth :

Sex (Enter “Male” or “Female” or “Transgender person”) :

Child’s details (If name is changed on adoption, write new name):-

Name of the Child

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mother’s Details (If known):-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Father’s Details(If known):-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Details of adoption deed / order:-

Date:

Number of Adoption deed / order:

Adoptive Mother’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Adoptive Father’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Address of adoptive parents as recorded in Adoption deed / order: House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Permanent address of adoptive parents: House No: Locality:

Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Place of birth: (Tick the appropriate entry 1 or 2 or 3 below and give the name and address of the “

Institution” or the address of the “House” or ‘Other place” where the birth took place) :

1.Hospital / Institution Name :

2. House 3. Other place Address : House No. Locality:

Ward number (in case of town and if available): Town or Village:

Sub-district: District:

State or Union Territory:

PIN Code:

If adoption through agency write the address of the Adoption agency: House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Informant’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No.(if available):

Mobile No:

Email Id:

Address : House No: Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

*As contained in the original birth certificate.

14.

(a)

(b)

15.

16.

17.

18.

To be filled by the informant

For

Religion

[Enter appropriate

religion

“Hindu” or Muslim” or “Christian” or “Sikh” or

“Buddhist” or “Jain” or “Other (Please specify)”]

Religion of Adoptive Father:

Religion of Adoptive Mother:

Adoptive Father’s level of education:

Adoptive Mother’s level of education:

Adoptive Father’s Occupation:

Adoptive Mother’s Occupation:

DECLARATION: I have furnished true information to the best of my knowledge and belief. I am aware of the

penalties under section 23 of the Registration of Births and Deaths Act, 1969 (amended in 2023) for submitting

false information. Also, I give consent, under Aadhaar (Targeted Delivery of Financial and Other Subsidies,

benefits and Services) Act, 2016, for authenticating identity by way of Aadhaar authentication.

(After completing all columns 1 to 18,

informant will put date and signature)

Date:

Signature or

left thumb mark of the informant

(Columns to be filled are over. Now put signature at left)

To be filled by the Registrar

Registration No. :

Registration Date:

Registration Unit :

Town / Village: Sub-District:

District:

Remarks ( if any):

Name and Signature of the Registrar

Name

Code No.

District

Sub-District

Town/Village :

Registration Unit : Registration No. :

Registration Date:

Date of Birth :

Sex : Male / Female / Transgender person

Place of Birth: 1. Hospital/Institution 2. House 3.

Other place

Name and Signature of the Registrar

To be detached and sent for statistical processing

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

Instructions for completing the Form 1-A: BIRTH REPORT FOR ADOPTED CHILD

Item No.

Instructions

1, 6

Date, wherever it occurs, is to be provided in dd-mm-yyyy format, where dd is date in two

digits, mm is month in two digits and yyyy is year in four digits Wherever the date is written in

words it should be written in full e.g 01-01-2023 shall be written as First January two thousand

twenty three.

If date of birth is unknown, record the date of birth as reflected in adoption order or deed, as

the case may be.

Use only 'Arabic numerals' such as 0,1,2,3,4,5,6,7,8,9 for recording dates and other

numerical entries.

Enter “Male” or “Female” or “Transgender Person”. Do not use abbreviation.

3,4,5,7,8,13

Name, wherever it occurs, is to be provided in the format of [first name] [middle name] [last

name] where full name (not abbreviation) to be written in capital letters and first name is

mandatory. There should be minimum two characters in either [first name] or [middle name]

or [last name].

9,10,11,12,13

Address, wherever it occurs, shall contain the name of State or Union Territory, District, Sub-

district, Town or Village, Ward number (in case of town and if available), Locality, House

number and PIN Code.

15,16

Level of Education – Write one of following—

1.Pre-

Primary

6.Class 5

11.Class 10

16.

Bachelor

Undergraduate

21. Literate without

formal education

2.Class 1

7.Class 6

12.Class 11

17. PG Diploma

22. Illiterate

3.Class 2

8.Class 7

13.Class 12

18.

Master

Post

graduate

4.Class 3

9.Class 8

14.ITI

19. M.Phil

5.Class 4

10.Class 9

15.Diploma

Certificate

20. Doctorate & above

(Enter the completed level of education e.g. if studied upto class VII but passed only class VI,

write class VI)

17,18

Occupation - Write one of following—

1. Cultivator

2. Agriculture Labourer

3. Daily Wages Earner(Other than Agriculture Labourer)

4. Single/Family Worker/Self Employed

5. Employer

6. Government Employee

7. Private Employee(Other than Domestic Helper)

8. Domestic Helper

9. Non-Worker

Note: The informant responsible for reporting birth event of adopted child shall be as per the Registration of Births

and Deaths Act, 1969 (amended in 2023).

The informant must ensure that no item in the form for Birth Report for Adopted Child is left blank to the extent

possible.

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

FORM NO.2 (See rule 5)

DEATH REPORT

Legal information

[SEE REVERSE FOR INSTRUCTIONS]

This part to be added to the Death Register

FORM NO.2 (See rule 5)

DEATH REPORT

Statistical information

[SEE REVERSE FOR INSTRUCTIONS]

This part to be detached and sent for statistical processing

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

(e)

(f)

10.

(a)

(b)

(c)

(d)

(e)

To be filled by the informant

Date of Death

Deceased’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Date of Birth (if available) :

Age:

Sex (Enter “Male” or “Female” or “Transgender person”) :

Mother’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Father’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Spouse’s (husband / wife) Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No.(if available):

Date of Birth (if available) :

Age (in completed years):

Mobile No:

Email Id:

Address of the deceased at the time of death: House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Permanent address of the deceased: House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Place of death (Tick the appropriate entry 1 or 2 or 3 below and give the name and address

of the “Hospital / Institution” or the address of the “House” or ‘Other place” where the death

took place) :

1.Hospital / Institution Name :

2. House 3. Other place Address : House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Informant’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No.(if available):

Mobile No:

Email Id:

Address : House No.:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

To be filled by the informant

Town or village of Residence of the deceased (Place

where the deceased usually lived. This can be different

from the place where the death occurred. Tick appropriate

entry “Town” or “Village” and write its name):

Town or Village: Sub-district:

District: State or Union Territory:

PIN Code:

Religion ( Enter appropriate religion “Hindu” or “Muslim” or

“Christian” or “Sikh” or “Buddhist” or “Jain” or “Other

(Please specify)”):

Occupation of the deceased:

Type of Medical Attention received before death (Tick

the appropriate entry below):

Institutional

Medical attention other than Institution

No Medical attention

Was the cause of death medically certified? (Tick the

appropriate entry below) :

1.Yes 2. No

Name of Disease or Actual Cause of Death (For all

deaths irrespective of whether medically certified or not) :

In case this is a female death, did the death occur

while pregnant, at the time of delivery or within 6

weeks after the end of pregnancy (Tick the appropriate

entry below):

1.Yes 2. No

If used to habitually smoke –

for how many years?

If used to habitually chew tobacco in any form –

for how many years?

If used to habitually chew arecanut in any form

(including pan masala) -

for how many years?

If used to habitually drink alcohol -

for how many years?

DECLARATION: I have furnished true information to the best of my knowledge and belief. I am

aware of the penalties under section 23 of the Registration of Births and Deaths Act, 1969

(amended in 2023) for submitting false information. Also, I give consent, under Aadhaar (Targeted

Delivery of Financial and Other Subsidies, benefits and Services) Act, 2016, for authenticating

identity by way of Aadhaar authentication.

To the best of my knowledge and information, the detail of Aadhaar of the deceased is not

available.

(After completing all columns 1 to 21,

informant will put date and signature)

Date:

Signature or left thumb mark of the informant

(Columns to be filled are over. Now put signature at left)

To be filled by the Registrar

Registration No. :

Registration Date:

Registration Unit :

Town / Village:

Sub-District:

District:

Remarks ( if any):

Cause of Death (as per Form 4 / 4A):

Name and Signature of the Registrar

Name

Code No.

District

Sub-District

Town/Village :

Registration Unit :

Registration No. :

Registration Date:

Date of Death :

Sex : Male / Female / Transgender person

Age of deceased:

Place of death : 1. Hospital/Institution 2. House 3. Other place

Name and Signature of the Registrar

To be detached and sent for statistical processing

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

FORM NO.3

(See rule 5)

STILL BIRTH REPORT

Legal information

[SEE REVERSE FOR INSTRUCTIONS]

FORM NO.3

(See rule 5)

STILL BIRTH REPORT

Statistical information

[SEE REVERSE FOR INSTRUCTIONS]

This part to be added to the Still Birth Register

This part to be detached and sent for statistical processing

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

(e)

To be filled by the informant

Date of Birth :

Sex (Enter “Male” or “Female” or “Transgender person”) :

Father’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Mother’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No.(if available):

Mobile No:

Email Id:

Place of birth (Tick the appropriate entry 1 or 2 or 3 below and give the name and

address of the “Hospital / Institution” or the address of the “House” or ‘Other place” where

the birth took place) :

1.Hospital / Institution Name :

2. House 3. Other place Address : House No. Locality:

Ward number (in case of town and if available): Town or Village:

Sub-district: District:

State or Union Territory:

PIN Code:

Informant’s Details:

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Address : House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

10.

11.

12.

To be filled by the informant

Town or village of Residence of the mother (Place

where the mother usually lives. This can be different from

the place where the delivery occurred. Tick appropriate

entry “Town” or “Village” and write its name):

Town or Village: Sub-district:

District: State or Union Territory:

PIN Code:

Age of the mother (in completed years) at the time

of this birth :

Mother’s level of education:

Type of attention at delivery (Tick the appropriate entry

below):

Institutional-Government

Institutional – Private or Non-Government

Doctor, Nurse or Trained Midwife

Traditional Birth Attendant

Relatives or others

Duration of pregnancy (in weeks) :

Cause of foetal death (if known):

(In the case of multiple births, fill in a separate form for

each child and write 'Twin birth' or 'Triple birth' etc., as

the case may be, in the remarks column in the box

below left.)

DECLARATION:

I have furnished true information to the best of my knowledge and belief. I am aware of the

penalties under section 23 of the Registration of Births and Deaths Act, 1969 (amended in

2023) for submitting false information. Also, I give consent, under Aadhaar (Targeted Delivery

of Financial and Other Subsidies, benefits and Services) Act, 2016, for authenticating identity by

way of Aadhaar authentication.

(After completing all columns 1 to 12,

informant will put date and signature)

Date:

M M

Signature or

left thumb mark of the informant

(Columns to be filled are over. Now put signature at left)

To be filled by the Registrar

Registration No. :

Registration Date:

Registration Unit :

Town / Village:

Sub-District:

District:

Remarks ( if any):

Name and Signature of the Registrar

Name

Code No.

District

Sub-District

Town/Village :

Registration Unit :

Registration No. :

Registration Date:

Date of Birth :

Sex : Male / Female / Transgender person

Place of Birth: 1. Hospital/Institution 2. House 3. Other place

Name and Signature of the Registrar

To be detached and sent for statistical processing

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

Instructions for completing the Form 3: STILL BIRTH REPORT

Item

No.

Instructions

Date, wherever it occurs, is to be provided in dd-mm-yyyy format, where dd is date in two digits, mm

is month in two digits and yyyy is year in four digits Wherever the date is written in words it should

be written in full e.g 01-01-2023 shall be written as First January two thousand twenty three. Use

only 'Arabic numerals' such as 0,1,2,3,4,5,6,7,8,9 for recording dates and other numerical entries.

Enter “Male” or “Female” or “Transgender Person”. Do not use abbreviation.

3,4,6

Name, wherever it occurs, is to be provided in the format of [first name] [middle name] [last name]

where full name (not abbreviation) to be written in capital letters and first name is mandatory. There

should be minimum two characters in either [first name] or [middle name] or [last name].

5,6

Address, wherever it occurs, shall contain the name of State or Union Territory, District, Sub-district,

Town or Village, Ward number (in case of town and if available), Locality, House number and PIN

Code.

For Place of birth tick the appropriate entry

1. Hospital / Institution

2. House

3. Other place

Give the name and address of the “Hospital / Institution” or the address of the “House” or ‘Other

place” where the birth took place.

Town or Village of residence of the mother: Place where the mother usually lives. This can be

different from the place where the delivery occurred. The house address is not required to be

entered.

Level of Education – Write one of following—

1.Pre-

Primary

6.Class 5

11.Class 10

16.

Bachelor

Undergraduate

21. Literate without

formal education

2.Class 1

7.Class 6

12.Class 11

17. PG Diploma

22. Illiterate

3.Class 2

8.Class 7

13.Class 12

18.

Master

Post

graduate

4.Class 3

9.Class 8

14.ITI

19. M.Phil

5.Class 4

10.Class 9

15.Diploma

Certificate

20. Doctorate & above

(Enter the completed level of education e.g. if studied upto class VII but passed only class VI, write

class VI)

12.

Cause of foetal death – Write one of following—

1. Bleeding (Hamorrhage)

7. Diabetes in the mother

13. Infection in the mother

Parvovirus B19

2. Problems with Placental

8. Infection in the mother

Coxsackie virus

14. Infection in the mother Q

fever

3. Problem with umbilical cord

9. Infection in the mother

Herpes simplex

15. Infection in the mother

Rubella (German measles)

4. Pre-eclampsia

10. Infection in the mother

Leptospirosis

16. Infection in the mother Flu

5. Genetic physical defect in

the baby

11. Infection in the mother

Lyme disease

17. Infection in the mother

Toxoplamosis

6. Liver disorder in the mother

(obstestric cholestas)

12. Infection in the mother

Malaria

18. Not stated

Note: The informant must ensure that no item in the Still Birth Report Form is left blank to the extent possible.

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

FORM NO. 4

(See rule 7)

MEDICAL CERTIFICATE OF CAUSE OF DEATH

(Hospital In-patients. Not to be used for still births)

To be sent to Registrar along with Form No. 2 (Death Report)

A copy of this certificate to be provided to the nearest relative of the deceased

Name of the Hospital ……………………………………………………………….

I hereby certify that the person whose particulars are given below died in the hospital in Ward No……………………..

NAME OF DECEASED:

First Name

Middle Name

Last Name

For use of Statistical Office

Sex

Age at Death

If 1 year or more,

age in years

If less than 1 year, age

in month

If less than one month,

age in days

If less than one day, age

in hours

Male

Female

Transgender

person

CAUSE OF DEATH

Immediate cause

State the disease, injury or complication which

caused death, not the mode of dying such as heart

failure, asthenia, etc.

Antecedent cause

Morbid conditions, if any, giving rise to the above

cause, stating underlying conditions last

Other significant conditions contributing to the death

but not related to the disease or condition causing it

(a) ……………………………………..

due to (or as a consequences of)

(b) ……………………………………..

due to (or as a consequences of)

….……………………………………..

Interval between onset

and death approx.

Manner of Death

How did the injury occur?

1. Natural 2. Accident 3. Suicide 4. Homicide

5. Pending investigation

If deceased was a female, was pregnancy the death associated with? 1. Yes 2. No

If yes, was there a delivery? 1. Yes 2. No

Name and signature of the Medical Attendant certifying the cause of death

SEE REVERSE FOR INSTRUCTIONS

at…………………….A.M. / P.M.

Date of verification :

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

MEDICAL CERTIFICATE OF CAUSE OF DEATH

Directions for completing the form

Name of deceased : To be provided in the format of [first name] [middle name] [last name] where full name (not abbreviation)

to be written in capital letters and first name is mandatory. There should be minimum two characters in either [first name] or

[middle name] or [last name]. If deceased is an infant, not yet named at time of death, leave blank.

Age : If the deceased was over 1 year of age, give age in completed years. If the deceased was below 1 year of age, give age in

months and if below 1 month give age in completed number of days, and if below one day, in hours.

Cause of Death : This part of the form should always be completed by the attending physician personally.

The certificate of cause of death is divided into two parts, I and II. Part I is again divided into three parts, lines (a) (b)

(c). If a single morbid condition completely explains the deaths, then this will be written on line (a) of Part I, and nothing more

need be written in the rest of Part I or in Part II, for example, smallpox, lobar pneumonia, cardiac beriberi, are sufficient cause of

death and usually nothing more is needed.

Often, however, a number of morbid conditions will have been present at death, and the doctor must then complete

the certificate in the proper manner so that the correct underlying cause will be tabulated. First, enter in Part I(a) the immediate

cause of death. This does not mean the mode of dying, e.g., heart failure, respiratory failure, etc. These terms should not be

appear on the certificate at all since they are modes of dying and not causes of death. Next consider whether the immediate cause

is a complication or delayed result of some other cause. If so, enter the antecedent cause in Part I, line (b). Sometimes there will

be three stages in the course of events leading to death. If so, line (c) will be completed. The underlying cause to be tabulated is

always written in last in Part I.

Morbid conditions or injuries may be present which were not directly related to the train of events causing death but

which contributed in some way to the fatal outcome. Sometimes the doctor finds it difficult to decide, especially for infant

deaths, which of several independent conditions was the primary cause of death; but only one cause can be tabulated, so the

doctor must decide. If the other diseases are not effects of the underlying cause, they are entered in Part II.

Do not write two or more conditions on a single line. Please write the names of the diseases (in full) in the certificates

as legibly as possible to avoid the risk of their being misread.

Onset : Complete the column for interval between onset and death whenever possible, even if very approximately, e.g., “from

birth” “several years”.

Accidental or violent deaths : Both the external cause and the nature of the injury are needed and should be stated. The doctor or

hospital should always be able to describe the injury, stating the part of the body injured, and should give the external cause in

full when this is shown. Example : (a) Hypostatic pneumonia; (b) Fracture of neck of femur; (c) Fall from ladder at home.

Maternal deaths : Be sure to answer the question on pregnancy and delivery. This information is needed for all women of child-

bearing age, even though the pregnancy may have had nothing to do with the death.

Old age or senility : Old age (or senility) should not be given as a cause of death if a more specific cause is known. If old age was

a contributory factor, it should be entered in Part II. Example : (a) Chronic bronchitis, II old age.

Completeness of information : A complete case history is not wanted, but, if the information is available, enough details should

be given to enable the underlying cause to be properly classified.

Example : Anaemia – Give type of anaemia, if known. Neoplasm – Indicate whether benign or malignant, and site, with site of

primary neoplasm, whenever possible, Heart disease – Describe the condition specifically; if congestive heart failure, chronic on

pulmonale, etc., are mentioned, give the antecedent conditions. Tetanus – Describe the antecedent injury, if known. Operation –

State the condition for which the operation was performed. Dysentery – Specify whether bacillary, amoebic, etc., if known.

Complications of pregnancy or delivery – Describe the complication specifically, Tuberculosis – Give organs affected.

Symptomatic statement : Convulsions, diarrhea, fever, ascites, jaundice, debility, etc., are symptoms which may be due to any one

of a number of different conditions. Sometimes nothing more is known, but whenever possible, give the disease which caused the

symptom.

Manner of Death : Deaths not due to external cause should be identified as ‘Natural’. If the cause of death is known, but it is not

known whether it was the result of an accident, suicide or homicide and is subject to further investigation, the cause of death

should invariably be filled in and the manner of death should be shown as ‘Pending investigation’.

In accordance with the provisions of section 10(2) of the Registration of Births and Deaths Act, 1969 (amended in 2023), a

certificate of cause of death shall be given to the Registrar and a copy of the same to the nearest relative of the deceased.

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

FORM NO. 4A

(See rule 7)

MEDICAL CERTIFICATE OF CAUSE OF DEATH

(For non-institutional deaths. Not to be used for still births)

(To be given to the person required under the Registration of Births and Deaths Act, 1969 (amended in 2023) to give information concerning the death to Registrar

along with Form No. 2 (Death Report)

I hereby certify that the deceased Shri/Smt./Km……………………………………………………..Son /Wife/ Daughter of ………………………………resident

of ……………………………………….. was under my treatment from ……………………… to ………………………. and he/she died

NAME OF DECEASED:

First Name

Middle Name

Last Name

For use of Statistical Office

Sex

Age at Death

If 1 year or more,

age in years

If less than 1 year, age

in month

If less than one month,

age in days

If less than one day, age

in hours

Male

Female

Transgender

Person

CAUSE OF DEATH

Immediate cause

State the disease, injury or complication which

caused death, not the mode of dying such as heart

failure, asthenia, etc.

Antecedent cause

Morbid conditions, if any, giving rise to the above

cause, stating underlying conditions last

Other significant conditions contributing to the death

but not related to the disease or condition causing it

(a) ……………………………………..

due to (or as a consequences of)

(b) ……………………………………..

due to (or as a consequences of)

….……………………………………..

Interval between onset

and death approx.

If deceased was a female, was pregnancy the death associated with? 1. Yes 2. No

If yes, was there a delivery? 1. Yes 2. No

Name and signature of the Medical Practitioner certifying the cause of death

SEE REVERSE FOR INSTRUCTIONS

at…………………….A.M. / P.M.

Date of verification :

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

MEDICAL CERTIFICATE OF CAUSE OF DEATH

Directions for completing the form

Name of deceased: To be provided in the following format of [first name] [middle name] [last name] where full name (not

abbreviation) to be written in capital letters and first name is mandatory. There should be minimum two characters in either [first name]

or [middle name] or [last name]. If deceased is an infant, not yet named at time of death, leave blank.

Age : If the deceased was over 1 year of age, give age in completed years. If the deceased was below 1 year of age, give age in months

and if below 1 month give age in completed number of days, and if below one day, in hours.

Cause of Death : This part of the form should always be completed by the attending physician personally.

The certificate of cause of death is divided into two parts, I and II. Part I is again divided into three parts, lines (a) (b) (c). If

a single morbid condition completely explains the deaths, then this will be written on line (a) of Part I, and nothing more need be

written in the rest of Part I or in Part II, for example, smallpox, lobar pneumonia, cardiac beriberi, are sufficient cause of death and

usually nothing more is needed.

Often, however, a number of morbid conditions will have been present at death, and the doctor must then complete the

certificate in the proper manner so that the correct underlying cause will be tabulated. First, enter in Part I(a) the immediate cause of

death. This does not mean the mode of dying, e.g., heart failure, respiratory failure, etc. These terms should not be appear on the

certificate at all since they are modes of dying and not causes of death. Next consider whether the immediate cause is a complication or

delayed result of some other cause. If so, enter the antecedent cause in Part I, line (b). Sometimes there will be three stages in the course

of events leading to death. If so, line (c) will be completed. The underlying cause to be tabulated is always written in last in Part I.

Morbid conditions or injuries may be present which were not directly related to the train of events causing death but which

contributed in some way to the fatal outcome. Sometimes the doctor finds it difficult to decide, especially for infant deaths, which of

several independent conditions was the primary cause of death; but only one cause can be tabulated, so the doctor must decide. If the

other diseases are not effects of the underlying cause, they are entered in Part II.

Do not write two or more conditions on a single line. Please write the names of the diseases (in full) in the certificates as

legibly as possible to avoid the risk of their being misread.

Onset : Complete the column for interval between onset and death whenever possible, even if very approximately, e.g., “from birth”

“several years”.

Accidental or violent deaths : Both the external cause and the nature of the injury are needed and should be stated. The doctor or

hospital should always be able to describe the injury, stating the part of the body injured, and should give the external cause in full

when this is shown. Example : (a) Hypostatic pneumonia; (b) Fracture of neck of femur; (c) Fall from ladder at home.

Maternal deaths : Be sure to answer the question on pregnancy and delivery. This information is needed for all women of child-bearing

age, even though the pregnancy may have had nothing to do with the death.

Old age or senility : Old age (or senility) should not be given as a cause of death if a more specific cause is known. If old age was a

contributory factor, it should be entered in Part II. Example : (a) Chronic bronchitis, II old age.

Completeness of information : A complete case history is not wanted, but, if the information is available, enough details should be given

to enable the underlying cause to be properly classified.

Example : Anaemia – Give type of anaemia, if known. Neoplasm – Indicate whether benign or malignant, and site, with site of primary

neoplasm, whenever possible, Heart disease – Describe the condition specifically; if congestive heart failure, chronic on pulmonale,

etc., are mentioned, give the antecedent conditions. Tetanus – Describe the antecedent injury, if known. Operation – State the condition

for which the operation was performed. Dysentery – Specify whether bacillary, amoebic, etc., if known. Complications of pregnancy or

delivery – Describe the complication specifically, Tuberculosis – Give organs affected.

Symptomatic statement : Convulsions, diarrhea, fever, ascites, jaundice, debility, etc., are symptoms which may be due to any one of a

number of different conditions. Sometimes nothing more is known, but whenever possible, give the disease which caused the symptom.

In accordance with the provisions of section 10(3) of the Registration of Births and Deaths Act, 1969 (amended in 2023), a certificate of

cause of death shall be given to the person required under this Act to give information concerning the death.

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

ÑßÑðëð– 5

çðü.No. Form-5

State

Govt.

Emblem

………….. çðÜ¨îðÜ

GOVERNMENT OF ....................

..................ǒवभाग/..(ÑßÙððÂðÑðëð ¸ððÜó ¨îÜÐð÷ ãððâð÷ çÆððÐðóÚðòÐð¨îðÚð ¨îð

ÐððÙð)……….

DEPARTMENT OF.............../. (Name of local body issuing certificate).

¸ðÐÙð ÑßÙððÂð-Ñðëð

BIRTH CERTIFICATE

(¸ðÐÙð और ÙðöÃÚðô Üò¸ðç¾àó¨îÜÂð ¡òÏðòÐðÚðÙð, 1969 (2023 मɅ संशोिधत) ¨îó ÏððÜð 12 / 17 ÃðÆðð….(Üð¸Úð ¨îð

ÐððÙð)..........¸ðÐÙð ÙðöÃÚðô Üò¸ðç¾àó¨îÜÂð (संशोधन) òÐðÚðÙð, .. (çðüäðð÷òÏðÃð òÐðÚðÙð ¨îð÷ ¡òÏðçðõòµðÃð ò¨î¦ ¸ððÐð÷ ¨îð

ãðæðá)............................¨÷î òÐðÚðÙð 8 / 13 ¨÷î ¡üÃð±ðáÃð ¸ððÜó ò¨îÚðð ±ðÚðð)

(Issued under Section 12 / 17 of the Registration of Births and Deaths Act, 1969 (amended in

2023) and Rule 8 / 13 of the ..... (Name of State)................... Registration of Births and Deaths

(Amendment) Rules............ (Year of notifying the revised rules).

Úðè ÑßÙððòÂðÃð ò¨îÚðð ¸ððÃðð èø Ǒक òÐðÙÐðòâðò®ðÃð çðõµðÐðð ¸ðÐÙð ¨÷î Ùðõâð âð÷®ð çð÷ âðó गई èø ¸ðð÷ ò¨î (çÆððÐðóÚð êð÷ëð)

...................................................... ………...... उप-ò¸ðâðð..............................................................................

ò¸ðâðð .................................................................Üð¸Úð ..................................... ¨÷î Üò¸ðç¾Ü Ùð÷ü £òââðò®ðÃð èø |

This is to certify that the following information has been taken from the original record of birth which is

the register for (local area/local body) .................................................................. of Sub-district

................................ of District .................................of State/Union territory ....................................

ÐððÙð/Name: ..........................................................................................

òâðü±ð/Sex................................................................................................

¸ðÐÙð òÃðòÆð/Date of Birth..........................................................................

¸ðÐÙð çÆððÐð/Place of birth.........................................................................

ÙððÃðð ¨îð ÐððÙð/Name of Mother................................................................

माता का आधार न॰ /Aadhaar No. of Mother:

X X

X X X X

òÑðÃðð ¨îð ÐððÙð/Name of Father ....................................................................

िपता का आधार न॰ /Aadhaar No. of Father:

X X

X X X X

×ðµµð÷ ¨÷î ¸ðÐÙð ¨÷î çðÙðÚð ÙððÃðð òÑðÃðð ¨îð ÑðÃðð / ÙððÃðð òÑðÃðð ¨îð çÆððÚðó ÑðÃðð/

Address of parents at the time of birth of the child : Permanent address of parents:

...........................................................

............................................................

...........................................................

............................................................

...........................................................

............................................................

………………………………………

……………………………………….

Ñðü¸ðó¨îÜÂð çðü®Úðð/Registration No :............. Ñðü¸ðó¨îÜÂð òÇÐððû¨î/Date of Registration................

ò¾ÑÑðÂðó/Remarks (if any).........................

¸ððÜó ¨îÜÐð÷ ¨îó òÃðòÆð/Date of issue:..............

ÑßðòÏð¨îðÜó ¨÷î èçÃððêðÜ/Signature of the issuing authority

ÑßðòÏð¨îðÜó ¨îð ÑðÃðð/ Address of the issuing authority

Ùðð÷èÜ/Seal

ÑßÃÚð÷¨î ¸ðÐÙð ¦ãðÙð þÙðöÃÚðô ¨îð Ñðü¸ðó¨îÜÂð çðôòÐðòäµðÃð ¨îÜ÷ü/ Ensure registration of every birth and death

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

ÑßÑðëð– 6

Form-6

çðü.No.

State

Govt.

Emblem

………….. çðÜ¨îðÜ

GOVERNMENT OF ....................

................ǒवभाग/..(ÑßÙððÂðÑðëð ¸ððÜó ¨îÜÐð÷ ãððâð÷ çÆððÐðóÚðòÐð¨îðÚð ¨îð ÐððÙð)…

DEPARTMENT OF.............../. (Name of local body issuing certificate).

ÙðöÃÚðô ÑßÙððÂð Ñðëð

DEATH CERTIFICATE

(¸ðÐÙð और ÙðöÃÚðô Üò¸ðç¾àó¨îÜÂð ¡òÏðòÐðÚðÙð, 1969 (2023 मɅ संशोिधत) ¨îó ÏððÜð 12 / 17 ÃðÆðð….(Üð¸Úð ¨îð

ãðæðá)............................¨÷î òÐðÚðÙð 8 / 13 ¨÷î ¡üÃð±ðáÃð ¸ððÜó ò¨îÚðð ±ðÚðð)

(Issued under Section 12 / 17 of the Registration of Births and Deaths Act, 1969 (amended in

2023) and Rule 8 / 13 of the ..... (Name of State)................... Registration of Births and Deaths

(Amendment) Rules............ (Year of notifying the revised rules).

Úðè ÑßÙððòÂðÃð ò¨îÚðð ¸ððÃðð èø Ǒक òÐðÙÐðòâðò®ðÃð çðõµðÐðð ÙðöÃÚðô ¨÷î Ùðõâð âð÷®ð çð÷ âðó गई èø ¸ðð÷ ò¨î (çÆððÐðóÚð êð÷ëð)

...................................................... ………...... उप-ò¸ðâðð..............................................................................

ò¸ðâðð .................................................................Üð¸Úð ..................................... ¨÷î Üò¸ðç¾Ü Ùð÷ü £òââðò®ðÃð èø |

This is to certify that the following information has been taken from the original record of death which

is the register for (local area/local body) .................................................................. of Sub-district

................................ of District .................................of State/Union territory ....................................

ÐððÙð/Name: ..................................................................................

ÙðöÃð¨î का आधार न॰ /Aadhaar No. of deceased:

X X X

X X

òâðü±ð/Sex.........................................................................................

ÙðöÃÚðô ¨îó òÃðòÆð/Date of Death............................................................

ÙðöÃÚðô ¨îð çÆððÐð/Place of Death............................................................

ÙððÃðð ¨îð ÐððÙð/Name of Mother..........................................................

माता का आधार न॰ /Aadhaar No. of Mother:

X X

X X X

òÑðÃðð ¨îð ÐððÙð/Name of Father……………………………………..…..…..

िपता का आधार न॰ /Aadhaar No. of Father:

X X

X X X

पित/पÂनी का नाम/Name of Husband / Wife……………….………..…...…

पित/पÂनी का नाम/Name of Husband / Wife:

X X

X X X

ÙðöÃð¨î ¨îð ÙðöÃÚðô ¨÷î çðÙðÚð ¨îð ÑðÃðð/

ÙðöÃð¨î ¨îð çÆððÚðó ÑðÃðð/

Address of the deceased at the time of death: Permanent address of the deceased:

...........................................................

............................................................

...........................................................

............................................................

……………………………………..

Ñðü¸ðó¨îÜÂð çðü®Úðð/Registration No :.............Ñðü¸ðó¨îÜÂð Ǒदनांक/Date of Registration................

ò¾ÑÑðÂðó/Remarks (if any).........................

¸ððÜó ¨îÜÐð÷ ¨îó òÃðòÆð/Date of issue:.....

ÑßðòÏð¨îðÜó ¨÷î èçÃððêðÜ/Signature of the issuing authority

ÑßðòÏð¨îðÜó ¨îð ÑðÃðð/ Address of the issuing authority

Ùðð÷èÜ/Seal

ÑßÃÚð÷¨î ¸ðÐÙð ¦ãðÙð þÙðöÃÚðô ¨îð Ñðü¸ðó¨îÜÂð çðôòÐðòäµðÃð ¨îÜ÷ü/ Ensure registration of every birth and death

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

FORM NO.7

(See rule 12)

BIRTH REGISTER

Legal information

This part to be added to the Birth Register

(a)

(b)

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

To be filled by the informant

Date of Birth:

Sex (Enter “Male” or “Female” or “Transgender person”) :

Child’s Details (If not named, leave blank) :-

Name, if any :

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Father’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Mother’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Address of parents at the time of Birth of the Child: House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Permanent address of parents: House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Place of birth (Tick the appropriate entry 1 or 2 or 3 below and give the name and address of the

“Hospital / Institution” or the address of the “House” or ‘Other place” where the birth took place) :

1.Hospital / Institution Name :

2. House 3. Other place Address : House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

(a)

(b)

(c)

(d)

(e)

Informant’s Details:

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Address : House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

DECLARATION:

I have furnished true information to the best of my knowledge and belief. I am aware of the penalties

under section 23 of the Registration of Births and Deaths Act, 1969 (amended in 2023) for submitting

false information. Also, I give consent, under Aadhaar (Targeted Delivery of Financial and Other

Subsidies, benefits and Services) Act, 2016, for authenticating identity by way of Aadhaar

authentication.

(After completing all columns 1 to 23,

informant will put date and signature)

Date:

Signature or

left thumb mark of the informant

To be filled by the Registrar

Registration No. :

Registration Date:

Registration Unit :

Town / Village:

Sub-District:

District:

Remarks ( if any):

Name and Signature of the Registrar

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

FORM NO.8

(See rule 12)

DEATH REGISTER

Legal information

This part to be added to the Death Register

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

(e)

(f)

10.

(a)

(b)

(c)

(d)

(e)

To be filled by the informant

Date of Death

Deceased’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Date of Birth (if available):

Age:

Sex (Enter “Male” or “Female” or “Transgender person”) :

Mother’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Father’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Spouse’s (husband / wife) Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Date of Birth (if available):

Age (in completed years):

Mobile No:

Email Id:

Address of the deceased at the time of death: House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Permanent address of the deceased: House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Place of death (Tick the appropriate entry 1 or 2 or 3 below and give the name and address of

the “Hospital / Institution” or the address of the “House” or ‘Other place” where the death took

place) :

1.Hospital / Institution Name :

2. House 3. Other place Address : House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

Informant’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No.(if available):

Mobile No:

Email Id:

Address : House No.:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

DECLARATION: I have furnished true information to the best of my knowledge and belief. I am

aware of the penalties under section 23 of the Registration of Births and Deaths Act, 1969 (amended in

2023) for submitting false information. Also, I give consent, under Aadhaar (Targeted Delivery of

Financial and Other Subsidies, benefits and Services) Act, 2016, for authenticating identity by way of

Aadhaar authentication.

To the best of my knowledge and information, the detail of Aadhaar of the deceased is not available.

(After completing all columns 1 to 21,

informant will put date and signature)

Date:

Signature or

left thumb mark of the informant

To be filled by the Registrar

Registration No. :

Registration Date:

Registration Unit :

Town / Village: Sub-District: District:

Remarks ( if any):

Cause of death (As per Form 4 / 4A):

Name and Signature of the Registrar

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

FORM NO.9

(See rule 12)

STILL BIRTH REGISTER

Legal information

This part to be added to the Still Birth Register

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

(a)

(b)

(c)

(d)

(e)

To be filled by the informant

Date of Birth :

Sex (Enter “Male” or “Female” or “Transgender person”) :

Father’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Mother’s Details:-

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Place of birth (Tick the appropriate entry 1 or 2 or 3 below and give the name and address of the “Hospital /

Institution” or the address of the “House” or ‘Other place” where the birth took place) :

1.Hospital / Institution Name :

2. House 3. Other place Address : House No. Locality:

Ward number (in case of town and if available): Town or Village:

Sub-district: District:

State or Union Territory:

PIN Code:

Informant’s Details:

Name:

First Name

Middle Name

Last Name

Aadhaar No. (if available):

Mobile No:

Email Id:

Address : House No:

Locality: Ward number (in case of town and if available):

Town or Village: Sub-district: District:

State or Union Territory:

PIN Code:

DECLARATION:

I have furnished true information to the best of my knowledge and belief. I am aware of the penalties under section 23 of

the Registration of Births and Deaths Act, 1969 (amended in 2023) for submitting false information. Also, I give consent,

under Aadhaar (Targeted Delivery of Financial and Other Subsidies, benefits and Services) Act, 2016, for authenticating

identity by way of Aadhaar authentication.

(After completing all columns 1 to 12,

informant will put date and signature)

Date:

Signature or

left thumb mark of the informant

To be filled by the Registrar

Registration No. :

Registration Date:

Registration Unit :

Town / Village:

Sub-District:

District:

Remarks ( if any):

Name and Signature of the Registrar

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

Form No. 14

(See rule 9)

Format of Self-attested document for Delayed Reporting of BIRTH / DEATH under Section

13(2) of the Registration of Births and Deaths Act, 1969 (amended in 2023)

DECLARATION

I…………………………………………………………,son/daughter/wife

…………….,resident of …………………………………………………………………………. do

hereby declare that:

1. I am the informant for the delayed reporting of Birth / Death of_____(name of child /

deceased)________________________son/daughter/spouse of ………………………………….;

2. He / she was born / died on ___(date of birth / death)_________________________ at (place of

birth / death)…………….;

3. He / she was attended at birth /death by _________________________ who resides

at___________;

The

reason(s)

for

the

delay

reporting

his

her

birth

/death

are

_______________________________________________________________________________

_______________________________;

His

her

birth

death

certificate

required

for

the

purpose

________________________________;

DECLARATION:

I, declare that the above information is true and I have not reported the above event to any

Registrar and no birth / death certificate has been issued in this respect, to the best of my

knowledge and belief.

Name and Signature or

thumb mark of the informant

Notes:

1. Date, wherever it occurs, is to be provided in dd-mm-yyyy format, where dd is date in two

digits, mm is month in two digits and yyyy is year in four digits Wherever the date is written in

words it should be written in full e.g 01-01-2023 shall be written as First January two thousand

twenty three. Use only 'Arabic numerals' such as 0,1,2,3,4,5,6,7,8,9 for recording dates and other

numerical entries.

2. Name, wherever it occurs, is to be provided in the format of [first name] [middle name] [last

name] where full name (not abbreviation) to be written in capital letters and first name is

mandatory. There should be minimum two characters in either [first name] or [middle name] or

[last name].

3. Address, wherever it occurs, shall contain the name of State or Union Territory, District, Sub-

district, Town or Village, Ward number (in case of town and if available), Locality, House number

and PIN Code.

Date

D D -

M M -

Y Y Y Y

THE LAKSHADWEEP GAZETTE EXTRAORDINARY

Form No. 15

(See rule 16 A)

FORM FOR APPEAL

(To be submitted to District Registrar / Chief Registrar)

(under Section 25(A) of the Registration of Births and Deaths Act, 1969 (amended in 2023))

1. Aggrieved by an action or order of: Registrar / District Registrar or any officer authorized to

act as Registrar / District Registrar (details of office to be provided as below)

State

District

Sub-

District

Village/Town Locality

Name of

Registrar / Distt. Registrar or

any officer authorized to act

as Registrar / District

Registrar

2. Account of Event Leading to appeal with date and order no. etc.

(Provide a detailed account of the occurrence, use attachments, if necessary)

DECLARATION:

I have furnished true information to the best of my knowledge and belief.

(Signature of the appellant)

Appellant details:

Name

Address

Aadhaar no.

Email Id

Mobile No.

--------------------------------------------------------------------------------------------------------------------------------

Notes:

1. Please retain a copy of this form for your own records.

2. Appeal, if any, must be submitted to District Registrar / Chief Registrar within a period of

days from the date of such action or receipt of such order with which the person is being

aggrieved.

3. Date, wherever it occurs, is to be provided in dd-mm-yyyy format, where dd is date in two

digits, mm is month in two digits and yyyy is year in four digits Wherever the date is

written in words it should be written in full e.g 01-01-2023 shall be written as First

January two thousand twenty three. Use only 'Arabic numerals' such as 0,1,2,3,4,5,6,7,8,9

for recording dates and other numerical entries.

4. Name, wherever it occurs, is to be provided in the format of [first name] [middle name]

[last name] where full name (not abbreviation) to be written in capital letters and first

name is mandatory. There should be minimum two characters in either [first name] or

[middle name] or [last name].

5. Address, wherever it occurs, shall contain the name of State or Union Territory, District,

Sub-district, Town or Village, Ward number (in case of town and if available), Locality,

House number and PIN Code.”.

By order of the Governor

(________________________)

Secretary to the Government of ………………

Date

D D -

M M - Y Y Y Y

LGP.KVT. L-293/5-24/5