ÈèÆåÀ¼úâ ¨ø×Ä . 11¹¶Èâ Ì±»Æ ¶ ¾Æ 11
Registration B 11
(A 4* S.,T. & E.) 8/58
Internet VersionÄÇ¸ Àò¨åÊÆ¨à (30 ïÉ¾ø Éª¾àºÆø )¥½·Æ¶Ì¶¸¹Æ ¼¶È¯Æ¯ÈÎ¸ (30 ¤ºÆ ¼Èâ)
DECLARATION OF DEATH (UNDER SECTION 30)(Àò¨åÊ¨Æå Ìè¾à ÄÇ¸Æ Ìèó Éì ï¨å µåÌïÆà ïÈà¨ ºæ¾ ïÉº´ ï¨Èè¾àÄ ÆæÑÄ Ì¿ÍåÆú)(¥½¹ÆÚ±Æ ±ºÆ¹¶Æ¶ ¼È ¹¶ÈÁÇ¿Ý¯ÆÐ ¼¶È¯Æ¯ÈÎ¸ Ì±»Æ¹Á¼Ç¾Æ Í·Í¼ £Ù¹Æ¹¹Æ¹´¾Æ ÍÁ®ÕºÆ°)(To be forwarded by the declarant direct to the Registrar of the division in which the death occurred)........................................................................................................................................................... ¼úÌàºòè¨à¨Æ´ ¡Æºà ................................... ï¨å µåÌïÆà Ìèó Éì ÄÇ¸Æ................................................................................................. ºÇÁ´Æ´¶Æ¶Èß¿Æ¿ ............................................. ¼È¾Æ º¼µºÆDeath in ................................................................................................ Division ..................................................................................... District
1. ÄÇ¸Æ ÌèóÉì ¼ú¾Æ Íå Ìà»å¾Æ
¥½·Æ¶ ¥´ÛºÆ ¶È¯¶ÈÜºÆ
Date and place of death
2. ÌÀìÚ¸ ¾åÄÆ ÌÍ À¼úâÆ 1
Ûá¹Æ Ì¹»ÝºÆ Á¶ÈÜºÈ´ÛºÆ 1
Full name and residence 1
3. Ìàºòé ÀêÇæË ÃåÉÆ ÌÍ °åºøÆ 2¹Ç¾Æ º½ÆÞºÆ Í¶±È» ¥¸ºÆ2
Sex and race2
4. ÉÆÌ
Á»×Age5. ººàºàÉÆ ï¾åïÍåºà ÉîºàºøÆ£·Æ¶ÃÆ× £¾Æ¾× Ì¶ÇÀÈ¾Æ
Rank or profession

6. ÄÉêÀèÆ¾àïªà ÌÀìÚ¸ ¾Ä
Ì¹½ÆÍ½Ç¼È Ûá¹Æ Ì¹»¼Æ
Parents’ full namesÀèÆåïªà¶¯¹Æ ¹ Father’sÄÉïªà¶Ç»Æ ÆMother’s

7. ÄÇ¸Æ´ ïÍàºëÉ Íå ¡å¼åÍ¾ ïÍåà ÃíÄ¼å¾ Ìà»å¾Æ
º¼µ¶Æ¶È ¯Ç¼µºÆ º½ÆÞºÆ Í¼¶¶ÆÎ¶£´¯Æ¯ºÆ £¾Æ¾× ¶¯¸³Æ Ì±»Æ¶ ¥´ºÆCause of death and place of burial or
cremation
8. Àò¨åÊ¨Æåïªà ÌÀìÚ¸ ¾Ä, À¼úâÆ Íå ¼æ¾ê
ï¼¾àï¾à ¨ÉÇ¨ë ÉÊïÆ¾à ¼ Æ¾à¾
¼¶È¯Æ¯ÈÎ¸ Ì±»Æ¹Á¼È Ûá¹ÆÌ¹»¼Æ,Á¶ÈÜºÈ´ºÆ; ©¸ ÛÎ½¾Æ ¶¯Á¾ÆÌ¯ÇÕ¯Æ¯È½Ç¼Æ ©¸Æ¹¸Declarant’s full name, residence and capacity
for giving information
9. ÄÇ¸Æ ÌèóÑÄ´ ïÍàºëÉ ¨ëÄ¨à¼æÆú Ì¿Í¾à ¨Ç¾à¡Äê¸å ºøïÂ¾ ÄÇ¸ ÌÍºø¨Æ ¾ø¨ëºà ¨Î ÈèÆåÀ¼èâ¨Ç¾ê ÈæÂì ïïÉ¼ñå®åñþÆåïªà ¾Äº¼µ¶Æ¶È ¯Ç¼µ¶Æ×¯ÆÐ£¶Æ¶Ç´Æ±È¹Æ¹¶Æ¶È¼¶ÆÎ¶ ÁÀ+Æ¯È» ¹¶ÈâÌ±»Æ»¹Æ¹´Æ´ ÎÁ¶Æ¶È»¼È Ì¹»¼Æ
Name of registered medical practitioner whosecertificate as to cause of death is annexed.
1.

“À¼úâ Ìà»å¾Æ” Æ¾à¾ Æ´ïºà ÉêÉÄ¾å É¾àï¾à ÄÎ ¡Æïªà Ìà»ýÇ ÉåÌÌà»å¾Æ Ì ¦à ¡Æïªà ºåÉ¨åÈè¨ ÉåÌÌà»å¾Æ ï¾åï. Ìà»üÇ ÉåÌÌà»å¾Æ ¾ªÇÆ¨ ÀèÍúïÆà ¾ïªÆú ¡â¨Æ, Ñ»üÆ Íå ¦Ä ¾ªÇïÆà ¾åÄÆ ¼ ¼úÆ ÆêºëÆú. ªÂ¼ ïÀï¼Ì¨ ÉìïÆà ¾, ¢¶ï, ªï ÌÍ ºæÀæÈà ¨¾àïºåàÇæï ¾ Ì¿Í¾à ¨Î ÆêºëÆ.

2.

ï¼ÄÎ °åºø¨Æè¾à Íå ÄÇ¨à¨È °åºø¨Æú¾à “Èåâ¨ø¨ ” ï¼ÄÎ ¾æºïÍåºà ÄÇ¨à¨È ¨øÆå ïÍåà “¢¾à¼úÆå¾ê ” ï¼ÄÎ ¾æºïÍåºà1.

“Á¶ÈÜºÈ´ºÆ” ©ÙºÆ ¸Ç¸Ç¾Æ ÍÁ®´¹Æ¹ÕÁ× ¥½·Æ¶Á¼È¸Æ ·È¼·Æ¶¼ºÇ¸ Á¶ÈÜºÈ´Íº»½È¶Æ ¶½Æ¯Ç¯ºÇ¯¯Æ ÐÝ¯ÆÐºÆ ¥´º¾Æ¾° ·È¼·Æ¶¼ºÇ¸Á¶ÈÜºÈ´ºÆ ­¼Æ ¹´Æ¸¶Æ¶È¾Ç ´Æ ¥¾¯Æ¯¶ÆÎ¶ÜºÆ Ì¶Ý Ì¹»Î¼ÜºÆ ¹´Æ¸¶Æ¶È Ì¹»Î¼ÜºÆ Ð½È¹ÆÕ¯° £× ¯È¼Çº¹Æ ¹Ð¶È¾ÇÍ¶Ç´Æ´¶Æ¶È Ì¹»Î¼ÜºÆ ¯È¼Çº¶Æ¶È Ì¹»Î¼ÜºÆ £³Æ±¾Æ £ßÁ¾¯¶Æ¶È Ì¹»Î¼ÜºÆ Ð½È¹ÆÕ¯°2.

¶ºÈÀ¼Æ £¾Æ¾× Í±Ç¸¯Î¼ “¥¾+ÆÎ¯¶Æ ¶ºÈÀ¼Æ” £¾Æ¾× “¥¾+ÆÎ¯±Æ Í±Ç¸¯¼Æ” £¾Æ¾× “¥·Æ¶È»¶Æ ¶ºÈÀ¼Æ” £¾Æ¾× “¥·Æ¶È» Í±Ç¸¯¼Æ” ©¸ Á¼È¶Æ¶¾ÆÍÁ®ÕºÆ°1.

What is required under “residence” is the permanent residence of the deceased and not any temporary place of abode. If the permanent residence
is in a town, state the number of house, name of street and name of town. If it is in a rural area, state the names of the garden and village including
the name of the Post Office.

2.

Tamils or moors must be described as “Ceylon Tamil” or “Ceylon Moor” or “Indian Tamil” or “Indian Moor” as the case may be.

ÄÇ¨à¨È ¨øÆå ÌàºÇ ¨Î ÆêºëÆú.

[¡¾ø¨à Àè´ ÂÈ¾à¾./ º°¹° ¹Ç° / P.T.O.

ÀÎÄêïÉ¾ø Àèï Ì¿Í¾à Àò¨åÊÆ ÌæÂç Éìºà ¾øÉæÇ¼ú Éìºà Àò¨åÊÆ¨à ÂÉ´ ïÄÆú¾à Àò¨åÊ ¨Ç.
20.................... ¨à Éì .........................................................................ÄÌ..................................................¼ú¾.............................................................................................................................¼û ¡ºàÌ¾à ¨Ç¾ È¼û.
Íº½Æç½È»× ±¼ÈÜºÆ §®ÎºÜÌº¸ ·Ç ¥¶Æ¶Ç½Æ ¼¶È¯Æ¯ÈÎ¸ Ì±»Æ¯ÈÍ½°20°°°°°°°°°°°°°°¤ºÆ ¤®Õ°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°° ºÇ¶ºÆ ° °°°°°°°°°°°°°°°°°°°°°°°°°°¤·Æ ¶È¯¶È»¸Æ Þ ·Ç°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°°¥¾ÆÎ¯Ì»Ç¹Æ¹ºÈÕ¯ÈÍ½¸Æ°I do hereby declare the above to be a ture and correct statement.
witness my hand at......................................................................................................................this.......................................................dayof..................................20...............

Êº 25¨ Äê¼à¼Ç
25 ±¶ Û¶Æ¶ÈÎ¼
Stamp of 25 cents........................................................................
Àò¨åÊ¨Æåïªà ¡ºàÌ¾¼¶È¯Æ¯ÈÎ¸ Ì±»Æ¹Á¼È¸Æ Î¯Ì»Ç¹Æ¹ºÆSignature of DeclarantÀÍº Ì¿Í¾à Ìå¨àËè¨ÇæÉ¾à ¢¼úÖÀè´ ¼û ¡ºàÌ¾à ¨Ç¾ È¼û :¯ÉÀÆ¯ÆÐ½È¹Æ´¹Æ¹´Æ´ ±Ç´Æ±È¯¿È Û®¸ÈÎ¾¾Æ Î¯Ì»Ç¹Æ¹ºÈ´¹Æ¹´Æ´× :Subscribed in the presence of :1 ïÉ¾ø Ìå¨àËñ¨Çæ :Û¶¾ÇÁ× ±Ç´Æ±È :1st Witness :-2 ïÉ¾ø Ìå¨àËñ¨Çæ :¥¼®´ÇÁ× ±Ç´Æ±È :2nd Witness :-ÌÀìÚ¸ ¾ÄÛá¹Æ Ì¹»¼Æ
Full NameÌÀìÚ¸ ¾ÄÛá¹Æ Ì¹»¼Æ
Full Name

À¼úâ Ìà»å¾Æ
ÆÁ¶ÈÜºÈ´ºÆResidence

À¼úâ Ìà»å¾Æ
ÆÁ¶ÈÜºÈ´ºÆResidence¡ºàÌ¾Î¯Ì»Ç¹Æ¹ºÆSignature¡ºàÌ¾Î¯Ì»Ç¹Æ¹ºÆSignature

H 022134 Êòé Èâ¨å Ç°ïÆà Äê÷¸ ï¼ÀåÚºï¾àºëÉÀò¨åÊ ¨Î ¡Æ Äê¼à¼ÇÆ ¤¶ ï¨ ¡ºàÌ¾ ÌÍ ¼åºÄ ïÆ¼úÆ ÆêºëÆú.
¼¶È¯Æ¯ÈÎ¸ Ì±»Æ¹Á¼Ç¾Æ ÒÝ¯ÆÌ¯Ç¹Æ¹ÛºÆ ¶È¯¶ÈÜºÈ´¹Æ¹´ ÍÁ®ÕºÆ°
To be initialled and dated by Declarant.