FORM 4
[See rules 18(2) and 21(1)]
Certificate

This is to certify that Shri/Smt./Kum…………………………………(name) with aliases, if any, and full address)…………….died at (place and district) on……………………………………………… (date in Christian era). His/Her death was due to non-natural cause(s) not being self-injury or suicide,
namely* ………………………...

Place	Date	Seal of Office	Signature of District Collector or District Magistrate

*Non-natural cause(s) to be specified here. Accidents due to external, violent and visible means, including rail and road accidents, electrocution, snake-bite, drowning, fire and attack by wild animal shall be treated as non-natural causes.