No. 41970   71 STAATSKOERANT, 12 OKTOBER 2018 DHA-1680 REPUBLIC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS home affairs Department: Home Affairs $ ?", Page 1 of 2 Annexure 7 DEATH REPORT BY AUTHORISED PERSON Serial number REPUBLIC OF SOUTH AFRICA [Births and Deaths Registration Act 51 of 1992] [Section 14(1)(b) ] To be completed in full and submitted at the Department of Home Affairs' office by the PERSON AUTHORISED by the Director-General where the medical practitioner has not certified the cause of death. The form must be completed in BLACK INK with BLOCK LETTERS and the fingerprints must be attached to the relevant space. Please mark the CORRECT box with R, where required. All fields are COMPULSORY. Incomplete, unclear and unreadable applications Instructions: Section A to be completed by the person authorised by the Director-General. Thumbprints of the deceased are compulsory and must be taken in the presence of the informant. The informant must verify, and where necessary, complete in full the personal particulars of the deceased. A. PARTICULARS OF DECEASED Identity number (passport if foreigner) Y Y Sex Y Y M M D D Date of death Y Y Y Y M M D D Right thumbprint of deceased Date of birth Citizenship Surname Previous/Maiden surname Forenames Place of death: Town Residential address: Left thumbprint of deceased Province Street Town Province Postal code Telephone no. (home) Marital status Single (mark with a tick Married No ne Education level of deceased, Specify only the highest class ü Gr R Widowed Gr 1 Gr 2 Gr 3 Divorced Gr 4 Gr 5 Gr 6 Gr 7 ) Gr 8 Gr 9 Gr 10 Gr 11 Gr 12 Form 1 Form 2 Form 3 Form 4 Form 5 NTC 1 NTC 2 NTC 3 Univ Tech Unkno wn Usual occupation of deceased: work done during most of working life Type of business / industry: Was the deceased a smoker five (5) years before death? B. CAUSE OF DEATH Yes No Do not know Not applicable (minor) *(Completed by Informant) 1. Provide full description of circumstances that led to the cause of death 2. Was the deceased ill immediately before his / her death? 3. If yes, for how long? 4. What was the nature of the illness? C. PARTICULARS OF INFORMANT (* Completed by Informant) Left thumbprint of informant Identity number (passport if foreigner) Citizenship Date of birth Y Y Y Y M M D D Sex Surname Previous / Maiden surname Forenames Residential address: Street Town Province Telephone number (home) Relationship to the deceased: Code Cell phone no. Parent Spouse Daughter /Son Other I, the undersigned, hereby declare under oath that I was present at the death of the person whose particulars appear in Part A and have accordingly informed the authorised person whose particulars appear in Part D and that the information submitted in this form and supporting documents is true and correct. I understand that a false statement is punishable under section 31 of the Births and Deaths Registration Act 51 of 1992. Date signed Signature Y Y Y Y M Place signed This gazette is also available free online at www.gpwonline.co.za M D D