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.