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Email Id
Death Person Information
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Date of Death
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Gender
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Age
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Years
Months
Days
Hours
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Name
Permanent Address Information
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Husband / Wife Name
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Father Name
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Mother Name
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Permanent Address
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Pincode
Same As Above Address
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Address at the time of Death
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Pincode
Place of Death
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Place of Death
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Hospital / Institute Name
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Door No
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Street Name
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State
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Religion
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Occupation of the Deceased
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Professional, Technical & Related Workers
Administrative Executive & Managerial Workers
Clerical & Related Workers
Sales Workers
Service Workers
Farmers, Fisherman, Hunters, Loggers etc., and Related Workers
Production & Other Related Workers, Transport Equipment Operators & Labourers
Workers whose Occupation are not elswhere classified
Non-Workers
Cooli
Labour Inspector
Teacher
Driver
Beedi Rolling
Doctor
Advocate
Computer Operator
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Tailor
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Home maker
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College Student
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Lineman
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BRICKLAYER
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Type of Medical Attention Received From Death
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Doctor Nurse or Trained Midwife
Traditional Birth Attendant
Relatives and Others
NO MEDICAL ATTENSION
Parvathi Amman Hosptial,Porayar
Institutional - Government
Institutional - Private or Non Government
Alpabet Hospital
Was the Cause of Death Medically Certified
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No
Yes
Name of Disease or Actual Cause of Death
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Cholera
Typhoid & Paratyphoid
Food Poisoning
Dysentry, Diarrhoea & Gastric - Enteritis
Tuberculosis
Leprosy
Diphtheria
Whooping Cough
Tetanus
Acute Poliomyelitis
Measles
Rabies
Malaria
Cancer
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Meningitis
Heart Disease and Heart Attacks
Pneumonia
Influenza
Bronchitis and Asthma
Jaundice
Chronic Liver disease and Cirrhosis
Ulcer of Stomach and Duodenum
Appendicities
Syphilis and other diseases of Genitourinary system
Abortions
Complications related to Pregnancy, Child Birth & Puerperium
Certain condition such as Birth-injuries, slow gowth of foetus & Prematuring originatingin the perinatal period
Cerebrovascular (Paralysis)
Senility
Others not elsewhere classified
Bites or Stings of Venomous animal
Accidental Burns
Falls & Drowning
Accidental Poisoning (Other than food poisoning)
Transport Accidents ( Railway, Road, Aircraft, Motor & Other Vehicles )
Other Accidents ( not elsewhere classified )
Suicide
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Chikan Box
Aged person
Blood Presure
others
Old Age
Kidney Failure
Natural Death
Brought Dead
Status Epilepppppptcus pulammary oclema
Sugar
shortness of breath
Drowning
Blood vessels
Cordio restorating
RESPIRATORY FAILURE
RHEUMATIC DISEASE
Brain Tumer
BLOOD CANCER
LIVER FAILURE
MATERNITY
Paralysis Disease
Mucus Blockage
EPILEPSY
Blood cancer
Hemiparesis
Cardiac arrest
Murder
Hiper tensen
BREATH DISORDER
Organ Failure
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
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No
Yes
If Used to Habitually Smoke
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No
Yes
Years
If Used to Habitually Chew Tobacco in any form
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No
Yes
Years
If Used to Habitually Chew arecaunt in any form (Including Panmasala)
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No
Yes
Years
If Used to Habitually Drink Alcohol
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No
Yes
Years
Remarks