COMMUNITY DEATH NOTIFICATION FORM

1. Names of Deceased:
2. Age of Deceased:
3. Village:
4. Parish:
5. Subcounty:
6. District:
7. NIN:	(if available)
8. Nationality of Deceased:	(N, R, F)
9. Probable Cause of Death:
10. Date of Death:	(yyyy-mm-dd)
11. Place of Death:	(Community/Health Facility)
12. Names of Person Reporting:
13. Phone # of person reporting:
14. Date of Submission of report:
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