Application for Issue of Death Certificate(s)

For Office use only

Total Amount
:
Number of Copies :
Receipt Number :
Date
:

To,
The Local Registrar,
Birth and Death,
Amritsar

Sir,
Kindly issue me the Death Certificate(s) as per details given below :
1. Date of Death (dd/mm/yy): _________/__________/___________
2. Sex

Male :

Female :

( Tick one)

3. Full Name of the Deceased :___________________________________________

4. Place of (Death Complete Address) : ____________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
5. Fathers Name / Husband Name of the Deceased : __________________________
6. Permanent Address at the time of admission : ______________________________
_____________________________________________________________________
_____________________________________________________________________
7. Place of Cremation . __________________________________________________
8. C.R. No. if the Deceased was admitted in the Hospital : ______________________
9. Relation of the Applicant with Deceased (Father / Mother / Relative ) : _________
_____________________________________________________________________
Note : Please remember Death Certificate can be sourced from the place of Death
only and from nowhere else in India.
Original copy of the Death Certificate is acceptable and not Photostat or attested
copy.

This Table helps you estimate the number of Death Certificates required. Death
Certificate is required for the following purpose.
S.No
1.
2.
3.
4.
5.
6.
7.
8

Purpose
Withdrawal of money from deceaseds bank account (one
certificate for each account)
For Lic Policy (One Certificate is required for each policy )
For getting Fixed Deposits transferred ( One Certificate is
required for each fixed deposit)
Share Transfer
For getting Fathers Job
For legal purpose (One Certificate is required for each case)
In Property Cases
Spare Copies
Total Number of Copies

Copies

To save your valuable time and money, reserve maximum number of copies.
Kindly issue me _____________________ copy(s) of death certificate as per detail
given above:
Yours Faithfully,

Signature
Name and Address: