FORM D4
REPUBLIC OF KENYA
DEPARTM ENT OF THE REGISTRAR-GENERAL
APPLICATION FOR LATE REGISTRATION OF A DEATH
(Occurred on or after 1-1-1982)
A. INFO RMATIO N REGARDING THE DECEASED
1. NAME………………………………………………………………………………………………………............................
First name Tribal (middle) name Father’s name (surname)
2. SEX: Male/Female* 3.AGE AT DEAT H……………4.DATE O F DEATH………………………
Year or M onth or Days
5. PLACE OF DEATH………………………………………………………………../ ……………………………………..........
Kijiji and sub-location or street and town District
6.PLACE OF BURIAL.
……………………………………………………………………………………………………/…………………..........................................
Kijiji and sub-location or street and town Sub-county
B. APPLICANT
1. NAME………………………………………………………………………………………………………………………………………………………...
First name Tribal (middle) name Father’s or husband’s * name (surname)
2. ADDRESS……………………………………………………………………………………………………………………………………………............
3. RELAT IONSHIP TO DECEASED…………………………………..4. .DAT E ………………………………5. ……………………………………….
Signature.
C. CERTIFICATE
(To be signed by Assistant Chief of sub-location and countersigned by Chief of location* *)
I, Registration Assistant for… ........................................................................................………………………………………….., hereby certify
Name of sub-location
that (insert full name of deceased)…………………………………………………………………………………………………………………..
First name Tribal (middle) name Father’ s name (surname)
Died/was buried*in my area and that to the best of my knowledge, the facts given are true.
………………………………………. …………………………………… …………………………………………….
Date Signed by R.A. Countersigned by S.R.A.
D. FO R USE O F DISTRICT REGISTRAR
Fee of KSh………………………………………………paid. Refer to Cash Receipt No. ………………………………………
Date……………………………………………… Signature………………………………………………..
……………………………………………………………………………………………………………………………………………………
*Delete inapplicable.
* *If certificate from Assistant Chief is not obtainable, a baptismal certificate or clinical card or doctor’s/midwife’s certificate should be produced.
GPK (SP) 7393—100m—07/2008
