Schedule-3

(Relating to Rule 5)

Death Notification Form

(To be filled by the informer)

The Local Registrar,

Ward No————————Rural Municipality/Municipality

————————————-District, —————-Province

Dear Sir,

I would like to give information of the death setting out the following details. It is requested that the death be registered according to the law.

1. Details of deceased person.

First Name: Middle Name: Surname:

Identification Number

Gender: Male    Female: Other:

Date of Birth: [B.S] (yy/mm/dd):__________ [A.D] (dd/mm/yy)________

Date of Death: [B.S] (yy/mm/dd): _________[A.D] (dd/mm/yy)__________

Date of Birth: [B.S] (yy/mm/dd):_____________ [A.D] (dd/mm/yy)_____________

Place of Death:   House ____    Hospital ______Other:__________

Death certified by doctor:      Yes: ________    No  ______

If mentioned, mention the reason behind the death mentioned in the certificate]

Address where the [Death occurred] {In case of abroad country name and local address}

2. Address of deceased person:

State: _____Rural Municipality /Municipality: _______Ward. No:_______

House No. _______Road/Marg _____Village/Tole:     _________

3. Other details of the deceased person:

Citizenship No/ District of issue/date of issue/identification number

In case of a foreigner [Passport No/ Issuing Country/Date of issue]

Marital Status: Married ________Unmarried_____     Widow/Widower  ____  Divorced_____

Separation ________

Educational Background:  _______  Occupation  ____    Religion: ______Janajati________

Grandfather’s First Name: ________Middle Name _______Surname  _________

Father’s First Name:________    Middle Name______ Surname  __________

Mother’s First Name: _______Middle Name: ______ Surname__________

4. In the case of the deceased being married

Mention the husband/wife’s name: (Including in the case of deceased)

5. The informer’s details:

Covenanting that the details mentioned herein are true and correct, and if proved false, I shall bear and pay, I, the informer, hereby sign:

First name ________Middle name ________Surname_______

Relationship with the deceased

Citizenship (if Nepali)___________

Citizenship certificate number/identification number

If foreigner, passport number in Nepali:

Name of the country of issue:_______

If foreigner, passport number in English:

Name of the country of issue:

Date when form filled up: (Y- M- D)

To be filled up by the Local Registrar

Documents to be attached:

1. Copy of citizenship certificate of the deceased (if issued):
2. Copy of citizenship certificate of the informer:
3. In the case of foreigner, copy of passport of the informer and the deceased, visa and evidence showing residence in the concerned Ward,