66   No. 41970 GOVERNMENT GAZETTE, 12 OCTOBER 2018 DHA-1663 A Page 1 of 3 G.P.-S. 09/09 A REPUBLIC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS GOV543/83 11/13 OG NOTICE OF OF DEATH DEATH // STILL STILLBIRTH NOTICE BIRTH [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) A. PARTICULARS OF THE DECEASED Instructions: Section A to be filled out by Authorised Medical Practitioner / Professional Nurse, who is responsible for examining the body to determine the cause of death. The Informant must verify, and where necessary, complete in full the personal particulars and other information of the deceased below. 1.1 Death 1.2 Still birth Stillbirth Left thumbprint of deceased death or or aastill stillbirth? 1. Was this a death birth? 2. Identification of the deceased (tick one box): 2.1 The deceased was identified with an ID document / passport (if foreigner) produced by the family 2.2 Still born child child Stillborn 2.3 The features of the deceased do not seem to match the features on the ID document or passport of deceased 2.4 ID document or passport of the deceased was not presented. The deceased was identified through word of mouth 2.6 The deceased was unidentifiable: 2.6.1 Burnt 2.6.2 Decomposed 2.6.4 DNA samples retrieved for identification purposes Y 3. Date of Death / stillbirth still birth Y Y Y 2.6.3 Other (specify) Right thumbpriint of deceased 2.5 The deceased was already buried prior to the completion of this form DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA 2.6.5 Dental records taken for identification purposes M M D D 4.1 Place of Death/still birth (City/Town/Village) stillbirth stillbirth 4.2 Province of Death/still birth 5. Place of Registration of Death / stillbirth still birth 6. If death occurred within 24 hours after birth, number of hours alive 7. Home telephone no. 8. Identity No. (Passport No. if foreigner) 9. Age at last birthday if DOB is unknown 10. Date of Birth if there is no ID number Y Y Y Y M M D D 11. Gender 11.1 Male 11.2 Female 11.3 Indeterminable 12. Surname 13. Previous / Maiden Surname 14. Forenames 15. Usual* Residential Address: Street Town Province Postal code 16. Citizenship 16.1 Place of Birth (City / Town / Village) or Country of Birth, if abroad 16.2 Province of Birth 17. Marital Status of the deceased 17.1 Single 18. Education level of deceased, (Specify only the highest class completed) None Gr R 17.2 Married Gr 1 Gr 2 Gr 3 17.3 Widowed Gr 4 Gr 5 Gr 6 17.4 Divorced Gr 7 Gr 8 Form 1 Gr 9 Form 2 Gr 10 Form 3 NTC 1 Gr 11 Form 4 NTC 2 Gr 12 Form 5 NTC 3 Univ Tech UnKnown (mark with a 5) 19. Usual occupation of deceased (type of work done during most of working life) 20. Type of business / industry: 1. Agriculture, hunting, forestry and fishing (mark with a 5 ) 2. Mining and quarrying 3. 4. Electricity, gas and Manufacturing water supply 21. Was the deceased a regular** smoker five years ago? (mark with a ; ) 5. Construction 8. Financial 6. Wholesale and 7. Transport, storage retail trade; repair of and communication intermediation, insurance, real motor vehicles, estate and motor cycles and business personal and services household goods; hotels and restaurants 21.1 Yes 21.2 No 21.3 Do not know 9. Community, social and personal services 10. Private households, exterritorial organisations, representatives of foreign governments & other activities not adequately defined 21.4 Not applicable (minor) * Where the deceased lived on most days. **Smoking tobacco on most days. GOV543-83T Notice of Death-Stillborn DHA1663 154183.indd 1 This gazette is also available free online at www.gpwonline.co.za 2013/11/14 06:41:37 AM