Example of DEATH CERTIFICATE

(Translated True Copy)

LALMOHAN SADAR HOSPITAL

Lalmohan, Bhola

Ref. No. Lal/gh/1220/1981

Date of Issue: 20/03/2006

DEATH CERTIFICATE

Name: MOHAMMAD MAHABUBUR RAHMAN

Father’s/Husband Name: Ali Ahammed Pandit

Age: 63        Sex: Male              Regn. No: 077203           Cabin/Bed: 04

Date & Time of admission: 03 January, 1981 at 11:00 a.m.

Date & Time of death: 11 January, 1981 at 7.30 p.m.

Cause of death: Cardio Respiratory Arrest

Dated:  ------------------------

Sd/- Illegible

05/01/1981

Dr. Moinuddin Mozumder (L.M.F)

LALMOHAN SADAR HOSPITAL

Lalmohan, Bhola