No. 41970   69 STAATSKOERANT, 12 OKTOBER 2018 NOTICE OF DEATH / STILLBIRTH Confirmation for Medical and Health use Only 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 theOF undertaker must be taken by the undertaker) NOTICE DEATH / STILL BIRTH D GOV543/83 11/13 OG FOLD TO THIS POINT This page must be sealed after completion to ensure confidentiality Confirmation for Medical and Health use Only (After completion seal to ensure confidentiality) ID No. (Passport No. if foreigner) File no File no ________________________ Date ________________ DHA-1663 B Page 1 of 1 FOLD TO THIS POINT Date G. MEDICAL CERTIFICATE OF CAUSE OF DEATH Instructions: Section G is to be filled out by Medical Practitioner /Professional Nurse / Forensic Pathologist , who has determined the cause of death PARTICULARS OF DECEASED 67. Identity No. (Passport No. if foreigner) 68. Gender 68.1 Male 68.2 Female 68.3 Indeterminable 69. Surname 70. Forenames 71. Population Group 71.1 African 71.2 White 71.3 Indian/Asian 71.4 Coloured 71.5 Other (specify) 72. Place of Death 72.1 Hospital/Inpatient 72.2 ER/Outpatient 72.3 DOA 72.4 Nursing Home 72.5 At home DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHA 72.6 Other (specify) 73. Name of Health Facility/Practice DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHA 74. Facility Contact Telephone No. incl. Area Code 75. Patient File No. 76. Contact Person at Facility: Surname Forenames Role/Rank G.1 FOR DEATHS OCCURRING AFTER ONE WEEK OF BIRTH Instructions: Section G.1 is to be completed for all deaths that occurred after one week of birth 77. CAUSES OF DEATH For office use only Enter the disease, injuries or complications that caused the death. Do not enter the mode of dying, such as cardiac or respiratory arrest, shock or heart failure. List only one cause on each line Part 1 Part 2 IMMEDIATE CAUSE (final disease or condition resulting in death) a) Due to (or as a consequence of) Sequentially list conditions, if any, leading to immediate cause. b) Due to (or as a consequence of) Enter UNDERLYING CAUSE last (Disease or injury that initiated events resulting in death) Due to (or as a consequence of) Approximate interval between onset and death (Days / Months / Years) ICD-10 c) d) Other significant conditions contributing to death but not resulting in underlying cause given in Part 1 78. If a female, was she pregnant at the time of death or up to 42 days prior to death? ( ; ) 82.1 Yes 82.2 No 79. Method used to ascertain the cause of death (tick all that apply): 79.1 Autopsy 79.2 Post mortem examination 79.5 Opinion of registered professional nurse 79.3 Opinion of attending medical practitioner 79.4 Opinion of attending medical practitioner on duty 79.6 Interview of family member 79.7 Other (specify) NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH G.2 FOR STILLBIRTHS AND DEATHS OCCURRING WITHIN ONE WEEK OF BIRTH (PERINATAL DEATHS) Instructions: Section G.2 is to be completed for all stillbirths still births and deaths that occurred within one week of birth (perinatal (prenatal deaths) deaths) Mother Child 80. Identity Number Y of Birth 81. Date Of Birth Y Y Y M M D D 90. Birth weight (in grams) 82. Age of last birthday/ DoB DOBunknown unknown 91.This birth was: 83. Number of previous pregnancies resulting in: 83.1 Live births 83.2 Stillbirths Still births 83.3 Abortions 91.4 Other multiple 92.2 During labour but before delivery 84.3 Abortion 85. Date of last previous delivery Y Y Y Y M M D D 86. First day of last menstrual period Y Y Y Y M M D D 92.3 Before delivery but not known whether before or during labour 93. If death occurred within 24 hours after birth, number of hours alive Or, if unknown, estimated duration of pregnancy (in completed weeks) 94. Attendant at birth: 87.1 Spontaneous 87.4 Vacuum extractor 94.1 Physician 87.2 Forceps delivery 87.5 Caesarean section 94.2 Trained midwife 87.3 Forceps and rotation 87.6 Other (specify) 94.3 Other trained person (specify) 88. Antenatal care two or more visits: 88.1 Yes 91.2 First twin 91.3 Second twin 92.1 Before labour 84.2 Stillbirth Still birth 87. Method of delivery: 91.1 Single birth 92. If still born, heartbeat ceased: 84. Outcome of last previous pregnancy (tick one): 84.1 Live birth 88.2 No 89.2 Live birth 89.1 Stillbirth Still birth 89. Type of death: NOTICEOFDEATHNOTICEOFDEATHNOTICEOFDEATHNOTICEOFDEATHNOTICEOFDEATHNOTICEOFDEATHNOTICEOFDEATHNOTICEOFDEATHNOTICEOFDEATHNOTICEOFDEATH 94.4 Other (specify) NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH NOTICEOFDEATH 88.3 Unknown 95. CAUSES OF DEATH a. Main disease or conditions in foetus or infant b. Other diseases or conditions in foetus or infant c. Main maternal disease or condition affecting foetus or infant d. Other maternal diseases or conditions affecting foetus or infant e. Other relevant circumstances 96. Autopsy information ( ; ) 96.1 Certified causes of death has been confirmed by autopsy 96.2 Autopsy information may be available later 96.3 Autopsy not performed GOV543-83T Notice of Death-Stillborn DHA1663 154183.indd 4 This gazette is also available free online at www.gpwonline.co.za 2013/11/14 06:41:40 AM