* Place of Death

Select Hospital House Other Places

* Hospital / Institute Name

Select

Door No

Ward No

Select

Street Name

Select

Death Address

Pincode

* State

Select Andra Pradesh Karanataka Kerala State Test Tamil Nadu test test state

* District

Select

* Town or Village

Select Town Village

* Town / Village Name

Type of Medical Attention Received From Death

Select Attension Type 5 Attension Type 6 Attention type 1 Attention Type 2 Attention Type 3 Attention Type 4

Was the Cause of Death Medically Certified

Select No Yes

Name of Disease or Actual Cause of Death

Select COVI-20 covid COVID-19 Fever Jaundice Mild Fever Nipha Virus Omicron Test Typhoid

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

Select No Yes

If Used to Habitually Smoke

Select No Yes

Years

If Used to Habitually Chew Tobacco in any form

Select No Yes

Years

If Used to Habitually Chew arecaunt in any form (Including Panmasala)

Select No Yes

Years

If Used to Habitually Drink Alcohol

Select No Yes

Years

Remarks