No. 41970   67 STAATSKOERANT, 12 OKTOBER 2018 DHA-1663 A Page 2 of 3 G.P.-S. 09/09 B REPUBLIC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS GOV543/83 11/13 OG NOTICE STILL BIRTH NOTICE OF OF DEATH DEATH / STILLBIRTH [Births and Deaths Registration Act 51 of 1992] [Regulations 11 and 14] To be completed in full and submitted at the Department of Home Affairs office by the informant or authorised funeral undertaker. The form to be completed in BLACK INK with BLOCK LETTERS. Please mark with 3 the CORRECT box, where required. All fields are COMPULSORY. Incomplete applications and applications that are not legible may be considered invalid. (Note: The fingerprints of the deceased, the informant and the undertaker must be taken by the undertaker) B. CERTIFICATE BY ATTENDING MEDICAL PRACTITIONER / PROFESSIONAL NURSE Instructions: Section B to be filled out by the same Medical Practitioner / Professional Nurse who completed Section A. 22.1 I, the undersigned, hereby certify that the deceased named in Section A, to the best of my knowledge and belief, died solely and exclusively due to Natural Causes 22.2 I, the undersigned, am not in a position to certify that the deceased died exclusively due to Natural Causes Particulars of the Medical Practitioner / Professional Nurse who filled out the form: 23. HPCSA Registration No. 24. Surname 25. Forenames 26. Name of Health Facility / Practice 28. Business Address: 27. Facility / Practice No. Street Town Province Telephone No. (Office) Postal Code Office stamp of health facility or practice I, the undersigned, hereby certify that I examined the body of the deceased named in section A and declare that the deceased, to the best of my knowledge and belief, died solely and exclusively due to natural or unnatural causes as indicated in paragraph 22 and in case this is not true, I shall be guilty of an offence and on conviction liable to a fine or to imprisonment for a period not exceeding five years or to both such fine and such imprisonment (Section 31(1)(b) of the Act 51 of 1992). Place signed DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA Y Date signed Y Y Y M M D D Si Signature t C. CERTIFICATE BY MEDICAL PRACTITIONER/ FORENSIC PATHOLOGIST Instructions: Section C to be filled out by Medical Practitioner or Forensic Pathologist, who is conducting medico-legal investigation of death. 29. I, the undersigned, hereby certify that a medico-legal investigation of death has been conducted on the body of the person whose particulars are given in Section A and that the body is no longer required for the purpose of the Inquest Act, 1959 (Act No. 58 of 1959) and the cause of death is: 30.1 Natural 30.3 Under investigation 30.2 Unnatural Y 31. Date of Post-mortem Y Y Y M M D D 32. Name of Medico-legal Mortuary / Mortuary 33. Mortuary No. 34. Mortuary Reference Number of Deceased 35. SAPS Case No. 36. Name of Police Station Particulars of the Medical Practitioner / Forensic Pathologist who filled out the form: 36.1 HPCSA Registration No. 37. Surname 38. Forenames 39. Business Address Street Town Province Postal Code Office stamp of mortuary Telephone No. (Office) I, the undersigned, hereby certify that I examined the body of the deceased named in section A and the deceased, to the best of my knowledge and belief, died solely and exclusively due to natural or unnatural causes as indicated on paragraph 29 and in case this is not true, I shall be guilty of an offence and on conviction liable to a fine or to imprisonment for a period not exceeding five years or to both such fine and such imprisonment (Section 31(1)(b) of the Act 51 of 1992.) Place signed Date signed Y Y Y Y M M D D Signature D. PARTICULARS OF INFORMANT Instructions: Section D to be completed by informant. Informant is responsible for certifying the identity of the deceased. 41. Date of Birth 40. Identity No. (Passport No. if foreigner) Y Y Y Y M M D D Left thumb print of informant 42. Citizenship 43. Surname 44. Forenames 45. Residential Address: Street Town Province Postal Code Telephone No. (Home) Cellphone No. 46. The Deceased is my: 46.1 Parent 46.2 Spouse 46.3 Child 46.4 Other, Specify I, the undersigned, hereby certify that the identity of the deceased mentioned in section A is to the best of my knowledge and belief true and correct in case it is not true, I shall be guilty of an offence and on conviction liable to a fine or to imprisonment for a period not exceeding five years or to both such fine and such imprisonment (Section 31(1)(b) of the Act 51 of 1992.) Signature DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA Date signed Y Y Y Y M M D D GOV543-83T Notice of Death-Stillborn DHA1663 154183.indd 2 This gazette is also available free online at www.gpwonline.co.za 2013/11/14 06:41:38 AM