1. The applicant declares that their father/mother/husband/wife/son/daughter named [NAME] died on [DATE] in [PLACE]. 2. The death was not previously registered with the local Panchayat or Municipality records. 3. The applicant is now requesting to register the death by paying any necessary late fees in order to have the death officially recorded.

1. AFFIDAVIT FOR DEATH REGISTRATION
I, _____________________ (Name of Applicant), S/o, D/o, W/o ______________,
aged about ___ years, resident of _________________________________(Address),
do hereby solemnly affirm and state as follows.
1. That my Father / Mother / Husband / Wife / Son / Daughter by name
______________________ (Name of Deceased) died on __________ (Date of
Death) at _________________ (Place of Death).
2. That the above said death was not registered in the Death Register of
Panchayat records / Municipal Records of ________________ (Name of the
Panchayat or Municipality under which the place of Death comes), resulting
there is no evidence on record.
3. Hence it is now requested that the above death be registered in the death
register of panchayat records / Municipal Records on payment of necessary
late fee by me, by condoning the delay.
4. I do hereby solemnly affirm that the above information as declared by me is
true and correct and necessary action under section 20 of the Registration of
Birth and Deaths Act may be taken, if the above information or any particulars
furnished by me proves to be wrong at any time and I may be kept responsible
for any commission in this regard.
Solemnly affirmed before me on _________ (Date of Signing
before Notary Public) at _____________ (Place of Signing)
NOTARY