| 1. Name of deceased :-
2. Age of deceased :-
3. Full Address:-
4. Name of Father/ Husband of deceased :-
5. Date of Expiry :-
6. Cause of death :- i) Natural ii) Accidental.
7. Name of applicant/Nominee and address :-
8. Relation with the deceased :-
9. Income of the deceased/bereaved family (Below Rs. 5,000/- per annum or more)
10. List of Members of the deceased :-
11. Whether there is landed property of the decease/bereaved family.
12. No objection certificate from other family members of the deceased.
Signature of applicant/Nominee
List of documents to be enclosed :-
1. Death certificate from the Registrar of Birth and Death/ Competent authority.
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