Scribd
Upload
11 views

Both

The document is a form for recording death information, including details about the place of death, health facility ownership, and the decedent's personal information. It consists of several sections that gather data on the decedent, date and cause of death, physician confirmation, and the person providing the information. The form is structured to ensure comprehensive documentation of death-related details.

Uploaded by

Gemechis Gurmesa
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
11 views

Both

The document is a form for recording death information, including details about the place of death, health facility ownership, and the decedent's personal information. It consists of several sections that gather data on the decedent, date and cause of death, physician confirmation, and the person providing the information. The form is structured to ensure comprehensive documentation of death-related details.

Uploaded by

Gemechis Gurmesa
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 2

Bakka Du’aa/ Place of Death

Hospitaala Buufata fayyaa Mana dhuunfaa


Hospital Health center Private home
Kilinika Keellaa fayyaa Kan biroo
Clinic Health station Other

Abbaa Dhaabbata Fayyaa/ Owner of the Health Facility

Mootummaa biyyaa Dhuunfaa, bu’aadhaaf


Local govt Private, for profit
Mootummaa alaa Dhuunfaa, bu’aa malee
Foreign govt Private, non-profit

Teessoo Dhaabbata Fayyaa/ Address of the Health Facility

Maqaa/ Name______________________________________________________________
Naannoo/State:______________________________________ Aanaa/County:___________
Godina/ District: ________________________________Ganda/ Village:____________ Lakk. manaa/ House no.:_______
Magaalaa/ City:_____________________ Lakk. bilbilaa/ Office phone no.:___________________________

Kutaa /Section 1: Odeeffannoo nama du’ee/ Decedent’s information

Maqaa guutuu/ Full name:________________________________________________________________________


Lammummaa/ Citizenship:_____________________________________Ittiin waamama/ Title:_________________
Umurii/ Age:_______ Guyyaa dhalootaa/ Date of birth:_____________________________Saala/Gender:_________

Kutaa /Section 2: Odeeffannoo du’aa/ Death information

Guyyaa dua’a Guyyaa/Day Yaroo


Date of death Guyyaa/Day Ji’a/Month Waggaa/Year Galgala/ Time Sa/Hr Da./Min
Evening
Lakk. bilbila maatii/ Family phone no.:__________________________

Kutaa /Section 3: Sababa du’aa/ Cause of death

A: ______________________________________________
B: ______________________________________________
C_______________________________________________

Kutaa/ Section 4: Ogeessa dua mirkaneesse/ Physician confirming death

Maqaa guutuu/ Full name___________________________________________Ogummaa/ Specialization:________


Guyyaa/ Date:_____________________________________Mallattoo/Signature:____________________________

Kutaa /Section 5: Odeeffannoo du’atii kana kan kenne/Person providing the death information

Maqaa guutuu/ Full name________________________________________________Guyyaa/Date:________________


Mallattoo/Signature:___________________________

Chaappaa/Stamp
Bakka Du’aa/ Place of Death

Hospitaala Buufata fayyaa Mana dhuunfaa


Hospital Health center Private home
Kliniika Keellaa fayyaa Kan biroo
Clinic Health station Other

Abbaa Dhaabbata Fayyaa/ Owner of the Health Facility

Mootummaa biyyaa Dhuunfaa, bu’aadhaaf


Local govt Private, for profit
Mootummaa alaa Dhuunfaa, bu’aa malee
Foreign govt Private, non-profit

Teessoo Dhaabbata Fayyaa/ Address of the Health Facility

Maqaa/ Name______________________________________________________________
Naannoo/State:______________________________________ Aanaa/County:___________
Godina/ District: ________________________________Ganda/ Village:____________ Lakk. manaa/ House no.:_______
Magaalaa/ City:_____________________ Lakk. bilbilaa/ Office phone no.:___________________________

Kutaa /Section 1: Odeeffannoo nama du’ee/ Decedent’s information

Maqaa guutuu/ Full name:________________________________________________________________________


Lammummaa/ Citizenship:_____________________________________Ittiin waamama/ Title:_________________
Umurii/ Age:_______ Guyyaa dhalootaa/ Date of birth:_____________________________Saala/Gender:_________

Kutaa /Section 2: Odeeffannoo du’aa/ Death information

Guyyaa dua’a Guyyaa/Day Yaroo


Date of death Guyyaa/Day Ji’a/Month Waggaa/Year Galgala/ Time Sa/Hr Da./Min
Evening
Lakk. bilbila maatii/ Family phone no.:__________________________

Kutaa /Section 3: Sababa du’aa/ Cause of death

A: ________________________________B: _____________________________C: ______________________________

Kutaa/ Section 4: Ogeessa dua mirkaneesse/ Physician confirming death

Maqaa guutuu/ Full name_____________________________________________Ogummaa/ Specialization:________


Guyyaa/ Date:_____________________________________Mallattoo/Signature:____________________________

Kutaa /Section 5: Odeeffannoo du’atii kana kan kenne/Person providing the death information

Maqaa guutuu/ Full name______________________________________________Guyyaa/Date:__________________


Mallattoo/Signature:___________________________

Chaappaa/Stamp

You might also like