ALL ENTRIES EXCEPT SIGNATURES TO BE MADE IN BLOCK CAPITALS ORIGINAL

FORM A 3
(See note on left -hand margin)
REGISTER OF DEATH
(For use by next-of-kin where no medical Registrar’s Serial No.
District: certificate of cause of death issue)
1. Full Name Baptismal or Middle or Surname or Tribal
of Deceased given Name (s) Tribal Name Name of Father

Son or
daughter of
2. Date Date of Month: : Year 3. Sex of Deceased
Of Month
Death Tick Male ............I
Appropriate
sex Female ..... 2
IMPORTANT:- A record must be made for each death. Use a typewriter or ball point with black or dark blue ink. This is a permanent legal record. Be sure that

.4 Age of ………………..years. If under one year state………………………. .5. Occupation of Deceased

Deceased Months.

If under one month state …………………………………….. days.

6. Exact Place No. of house and street or road, Name or Town, if any, or If any If in Institution-name
of Death of
if any Village/Sub-location and Location hospital or medical centre

7. Normal If Deceased not normally resident at above place, state district in which he lived.
Code Residence
Of Deceased
8. CERTIFICATE TO BE GIVEN BY RELATIVE OR OTHER INFORMANT WHERE NO MEDICAL CERTIFICATE GIVEN.

A. Apparent Cause of Death (Place tick in box against description which most nearly describes condition before death):

1. Natural Causes:
Bellyache, with diarrhea Sudden death Fever with headache & Other known cause, specify
Bellyache, without diarrhea Difficulty or pain in passing urine stiff neck condition: ….………………………
Cough, with short illness ( less Yellow skin or yellow eyes Other fever
than 1 month) Smallpox Convulsions with lock- ……………………………………..
Cough, with long illness ( more Measles jaw (tetanus)
than 1 month)
Shortness of breath & swelling Woman dying in child- ……………………………………..
of legs birth

I am satisfied after inquiry that the above-mentioned death is not one to which sections 386 or 387 of the Criminal Procedure Act (Cap. 75) apply.
An external examination of the body has/has not been made by a medical practitioner.
.................................
Deputy Registrar
Magistrate/Police Officer
2. Unnatural Causes:

(A disposal certificate in these cases can ONLY be given by the police when satisfied that the provisions of Cap. 75 have been observed).
the carbon copy is legible.

Accident Killed by another person Cause unknown

Attack by animal or snake Suicide
3. Certificate
I certify that I am (state relationship to deceased or capacity in which information given)
…………………………………………………………….... ...............................................................................................................

……………………………………………..and that the above information is correct to the best of my knowledge.

Signature .................................................................... . Date .......................................

(If illiterate, witness to mark of informant to sign)

9. Signature of Local Registrar ............................................. ………………………………. Date record received ...................................

GPK (L)