| SI no | | |
| IP no | | |
| Died in | | Tresor Nursing Home |
| under | | Surgery |
| Unit | | |
| on | | 18-11-2006 | |
| at | | 12-40am |
| Name of deceased | | Mrs Margarite |
| Date of birth | | 27-6-1919 |
| Age | | 87 |
| Sex | | F |
| Religion | | Christy |
| Marital status | | Divorcee |
| Occupation | | Educationist |
| Date and time of admission | | 19/9/2006 10AM |
| Name of Father/Mother/Huband/wife | | Not known |
| Address | | 'Abhiseka' |
| | | Nr 9, Padminitottam |
| | | Kurchikuppam |
| | | Pondicherry - 605012 |
| Cause of death | | Taxemia & severe bronchopneumonia |
| Immediate cause | | |
| Antecedent causes | | |
| (a) due to (or as a consequence of) | | old age with hypertension |
| | | and arthritis both knee |
| (b) due to (or as a consequence of) | | old age |
| Other significant conditions | | Not applicable |
| Accident/Suicide/Homicide | | Not applicable |
| Death associated with pregnancy | | No |
| If yes, was there a delivery | | No |
| Disposal of body | | Handed over to relatives |
| Date and time of certification | | 18-11-2006 12.40AM |
| Signature, name and designation | | Dr T R Mitra |
| of the certifier | | Consultant Surgeon |