Sample Death Certificate necessary if someone dies. Usually the letter is issued by the local village. This letter is usually used for managing the transfer of inheritance, insurance, deletion of the list of family members and so on.
For making a death certificate, there are several requirements that serve as evidence that a person has died and relatives have the right to apply for a death certificate to the village.

Sample Death Certificate

Requirements for Making a Death Certificate:

  1. Death certificate from local RT or RW
  2. Certificate of death from the hospital (if he died in the hospital)
  3. Statement letter from relatives (if death at home)
  4. Family card
  5. Identity card of the deceased

If all the documents are complete, you can directly come to the village for processing the certificate. Actually a death certificate can also be upgraded to a higher level called a death certificate. The deed can be processed at the population and civil registration office by attaching a death certificate from the kelurahan.

Structure of Making Death Certificate

  1. Complete official letterhead along with the path
  2. Description of the letter along with
  3. Reference number
  4. Foreword
  5. Identity of the deceased
  6. Complete information when he died and where he was buried

Sample Death Certificate



Jl. Hasanudin, Argo Mulyo District, Jayakarta Regency, West Java

================================================== =======================


No. 05/KLJATNEG/X/2015

I, the undersigned, Head of Jatinegara Village, Jayakarta Regency, West Java, Explain that:

Name : Adigang Adigung

Place/Date of Birth : Jayakarta, 15 July 1980

Occupation: BUMN employee


Address : Jalan Simatupang Raya No. 13 Jati Negara, Jayakarta Regency


On :

Day / date : Saturday / January 15, 2014

Time: 14.25 WIB

Place : Jalan Simatupang Raya No. 13 Jati Negara, Jayakarta Regency

Buried at: TPU Hidayatullah

Thus, this death certificate is made truthfully so that it can be used properly.

Jayakarta, January 18, 2014

Head of Jatinegara Village

Muhammad Anwar Saib

Here was sample death certificate issued by the kelurahan, for more details you can edit it yourself according to the real data. The example above is a simple example, you can also develop it yourself, of course using standard structure and language.