Application for late Registration of Death

To The Revenue Divisional Officer ____________ Division ____________ District.

Sir, Sub:Request for issue of Death Certificate of my wife/husband/son/ daughter/mother/father Regarding. --:0:-I, ________________________________ S/o. _________ years, D/o. W/o. _________________________ aged

Occupation_________________, resident of Door No. ____________Street

________________ Mandal _____________________ of _____________ District, Andhra Pradesh submit the few lines of kind perusal and favourable consideration.

I submit that that my wifes/husbands/fathers/mothers name is ______________________. That my father/mother/wife/son/daughter/was died on ___________________ (dd/mm/yyyyy) at Door No.________ (village/town)__________________ (Mandal)________________________ of

__________________District due to (cause of death)___________________. The information regarding the death of my father/mother/son/daughter was not informed to the local Birth and Death Registration Authority of _________________Mandal/Municipality. is not recorded The in said Resulting the the & death Death is entry of my of for

father/mother/wife/son/daughter _____________________

Birth

Register required

Mandal/Municipality.

death

certificate

___________________________ purpose.

enclose

herewith

the

Non-availability

certificate

of

Death

issued

by

the

Gram

Panchayath/Municipal Commissioner,_________________ along with Xerox copies of Ration Card and SelfAffidavit. Therefore, I request to kindly issue necessary orders to the Commissioner, ________________ Municipality/Panchayat Secretary _______________ Gram Panchayat, ______________ Mandal to make necessary entry of date of death of my father/mother/husband/son/daughter and issue Death Certificate at the earliest possible. Yours faithfully Signature of the Applicant Mobile No. Copies to be enclosed: 1. Application form* 2. Non-availability certificate issued by the Municipal Commissioner/Gram Panchayath* 3. Ration Card# 4. Self-Affidavit* 5. Supporting document of death, if any #

*- mandatory

# - any one