BMD Certificate template: Death
Use this form to send me information from a Death Certificate
Questions 1-12 appear in the order in which the information appears on the Death Certificate
1. Registration District *
Your answer
2. Death in the Sub-district of: *
Your answer
3. In the county of: *
Your answer
4a. Date of death *
MM
/
DD
/
YYYY
4b. Where died: *
Your answer
5. Name and surname: *
Your answer
6. Sex *
7. Age *
Your answer
8. Occupation: *
Your answer
9. Cause of death: *
Your answer
10. Name, description and residence of informant: *
Your answer
11. Date registered: *
MM
/
DD
/
YYYY
12. Name of registrar: *
Your answer
Anything you want to add?
Your answer
YOUR NAME *
Your answer
YOUR EMAIL ADDRESS *
Your answer
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