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CDMA Death Corrections Application Form PDF

This document is an application form for correcting details on a death certificate such as the deceased's name, date of death, gender, parents' names, death place, addresses, and informant details. It requires information about the original death certificate and deceased, proposed corrections, and supporting documents. The applicant must sign the form and can choose manual or postal delivery for the corrected certificate.

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FloydCorrea
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253 views2 pages

CDMA Death Corrections Application Form PDF

This document is an application form for correcting details on a death certificate such as the deceased's name, date of death, gender, parents' names, death place, addresses, and informant details. It requires information about the original death certificate and deceased, proposed corrections, and supporting documents. The applicant must sign the form and can choose manual or postal delivery for the corrected certificate.

Uploaded by

FloydCorrea
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Price: `1

CDMA Death Corrections Application Form

Death Details:-

District: __________________________ Registration Unit Id: _____________________________________


Registration Number: _______________ Registration Year: _____________ Death Year: _________________
Location:  Greater Municipality  Municipality  Municipal Corporation  Gram Panchayat
Gender: Male Female

Corrections Required in Death Certificate Details:-


Whether You Want to Update Deceased Name: Yes No

Changed Child Surname: ___________________ Changed Child Name:: _____________________________

Whether You Want to Update Date of Death: Yes No

Changed Date of Death: _________________________

Whether You Want to Update Gender: Yes No

Changed Gender: Male Female

Whether You Want to Update Deceased Father Name: Yes No

Changed Father Surname: ____________________ C


Changed Father Name: ___________________________

Whether You Want to Update Deceased Mother Name: Yes No

Changed Mother Surname: ___________________ C


Changed Mother Name: ___________________________

Whether You Want to Update Death Place: Yes No

Changed Death Place: ___________________________

Whether
her You Want to Update Address aat the Time of Death: Yes No

Changed Line 1 of Address at the Time of Death:: _________________________________________________

Changed Line 2 of Address at the Time of Death: _________________________________________________

Changed Line 3 of Address at the


he Time of Death:: _________________________________________________

Whether You Want to Update Permanent Address: Yes No

Changed Line 1 of Permanent Address: ________________


________________________________________________________
________________________________________

Changed Line 2 of Permanent Address: ________________________________________________________

Changed Line 3 of Permanent Address: ________________________________________________________


Price: `1

Informant Details:-
Informant Name: _________________________________________________________________________

Informant Relation: S/o  D/o  w/o  H/o  M/o  F/O  C/o

Informant Address1:: ______________________________________________________________________

Informant Address2:: ______________________________________________________________________

Informant Address3: ______________________________________________________________________

Mobile Number: ____________________ Email ID: ______________________________________________


______________________________________

Remarks: _______________________________________________________________________________

Pin code: ___________________ Delivery Type: Manual / In Person  Post – Local  Post - Nonlocal

Purpose of the Certificate ___________________________________________________________________

No of copies: ________________

Applicant’s Signature

Document List:-

1. Application Form*
2. Original Death Certificate issued by the Registrar of Death
3. In case of Medico Legal cases for death events, certificate from the concerned police authority is a must
along with FIR and postmortem report
4. Notary Affidavit on Rs.10/- Non
Non-Judicial Stamped paper
5. Available Documentary evidences like educational certifi
certificates,
cates, Election ID Card, Ration Card, Passport,
Driving License and Marriage certificates
6. A letter from the Hospital Authorities where the Death has occurred

Note: Please upload Application Form and any one of Above Documents as a single file in pdf format

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