Date of Birth of Deceased: {{patient.birthdate | bahmniDate}} Date of Admission: {{visitSummary.admissionDetails.date | bahmniDate}} Ward No: {{bedDetails.bedNumber}}

Date and Time Of Death: {{dateAndTimeOfDeath | bahmniDateTime}} NID No:{{DeceasedNID}} ({{nidOf}}) NID No:{{SpouseNID}} ({{nidOf}}) NID No:{{ParentsNID}} ({{ParentsNID}})

Frame A: Medical data: Part 1 and 2

1
Report disease or condition directly leading to death on line a

Report chain of events in due to order (if applicable)

State the underlying cause on the lowest used line

Cause of death

Time interval from onset to death

2
Other significant conditions contributing to death
(time intervals can be included in brackets after the condition)

Frame B: Other medical data

Was Surgery Performed Within The last four Week	{{frameBSurgeryPerformedLastWeek}}
If Yes Please Specify Date of Surgery	{{frameBSpecifyDate\| bahmniDateTime}}
If Yes Please Specify Reason for Surgery Disease or Condition	{{frameBSpecifyReason}}
Was an Autopsy Requested?	{{frameBAutopsyRequested}}
If Yes, were the Findings used in the Certification	{{frameBCertification}}
Manner of Death	{{mannerOfDeath}}
If external cause or poisoning:	{{externalPoisoning}}
Date of Injury	{{dateOfInjury \| bahmniDate}}
Please describe how external cause occurred (If poisoning please specify poisoning agent)	{{describePoisoning}}
Place of Occurrence of the external cause	{{placeOfOccurrence}}
Other Place (Please Specify):	{{otherPlace}}

Fetal or infant Death

Multiple Pregnancy	{{multiplePregnancy}}
Stillborn?	{{stillBorn}}
If death within 24h specify number of hours survived	{{numberOfHour}}
Birth weight (in grams)	{{birthWeight}}
Number of completed weeks of pregnancy	{{weeksOfPregnancy}}
Age of mother (years)	{{ageOfMother}}
If death was perinatal, please state conditions of mother that affected the fetus and newborn	{{newBorn}}

For women of reproductive age