AFFIDAVIT

SPECIMEN OF LATE REGISTRATION OF DEATH

I -------------------S/O resident of H.N0 -----

----do here by solemnly affirm and decline as

under : -

1. That my father/Mother/Wife/Sh./Smt. ---------

-------------------S/O/W/O Sh. ---------------

r/ o -------------------died -----------------

on -------------------at --------------------.

2. That the death event of Sh./ Smt. ------------

----------------------S/O/W/O Sh. ------------

----------------------died on ----------------

could not be reported to the Registrar, Births

& Deaths, Nager panchyat Ashrafpur Kichocha

due to some unavoidable circumstances .

3. That Sh. / Smt. ------------------------------

S/O/W/O Sh. ----------------------------------

was suffering from --------------------------.

4. That body of Sh. / Smt. ----------------------

S/O/W/O Sh. ---------------- -----------------

was cremated at cremation Ground Sector ----

on -----------------------.

5. That is prayed that the death event of Sh. /

Smt. -------------------------may be egistered

in the record of death of nager panchyat

ashrafpur kichocha .

Deponent

VERYFICATION :-

Verified that the contents of this affidavit are true and correct to the best of my knowledge and belief and nothing has been concealed therein .

Deponent