Royal Saudi Arab
(Logo)
Home Ministry
Name: Abdul Malek
Nationality: Bangladesh
Age: 56 Years
Date of birth: 30/11/1961
Hospital: MC ………………..
Regi no: 98815
Division: CCU
Form to Inform Dead News
The form is to be filled out as soon as the patient got dead
Profession Passport or work permit no:
Name of father of the dead person: Late Samed Ali Nationality: Bangladeshi
Name of mother of the dead person: Late Moyful Begum Date of birth: 30/11/1961
Home Address of dead person: Hazipur
Place of dead: KCO H (Hospital)
Diagnosis of admission: Chomolgic Vos
Gregorian Calender: 13/4/2017
Date of admission: 16/7/1438
Hizri Calender: ……………………………………….
Reason of Dead
First disease or reason which may direct cause of dead: Sudden pressure on the heart, weakness on muscle, rapid increase the percent of sugar in blood, increase of potassium in blood and low blood pressure.
(B) Other reason that may related to the dead but not related to it:
Date of dead: 19/7/1438
Time: hour min
Yes English date: 16/4/2017 Arabic date: 19/7/1438 Hizri
Name of doctor examined: …………………………………..
Signature: ……………………………………………..
Name and address of the relation with the dead person:
Name of doctor who treated: Fazle Mohammad
Signature: ……………………………………………………..
Official Stamp: ……………………………………………….
Doctor of the hospital: …………………………………..
Signature: ……………………………………………………….
Official Seal: …………………………………………………….
Royal Saudi Arab
Home Ministry,
Asir General Directorate Related to Health
Khamis Musaiyet General Hospital
Home Ministry
No: 4474/4141
Date: 2/4/1438 Hizri
Attested: …………………
Dead Report
Name of dead person Abdul malek Samed Ali Age: 56 Sex: Male
Nationality Bangladeshi English 1437- 48637
Date of got admitted in the hospital: 16/7/1438 Time: 5:30 Min
The person mentioned above made admitted in the hospital in that situation that sudden decrease in the heart and too much muscle weakness and very much increase of the sugar in the blood and traffin and increase of potassium and decrease of blood pressure.
Date of dead: 19/7/1438 Hizri
Time of dead: 2 AM in the morning
Reason of dead: As usual dead
Doctor Saleh
Doctor Fatema Signature: Illegible
Date: 6/7/1438
5072 Date: 19/7/1438 Hizri Report will be received on that
Name of mentioned doctor to resolve the issue of the subject: Please inform.
Thanking……….
Director, Khamis Al Mushaiyet General Hospital Ali Fahad
Successor approval and power letter to send deadbody in Bangladesh
Dead: Abdul Malek Father: Late Samed Ali Village: Hazipur (Malbari)
Post office: Police Station: Bhola District: Bhola
Dated 16/04/2017 got dead in the city Kamish Al Moshet in the Saudi Arabia. The alive successors are as bellow (In case of necessary separate successor letter can be attached.
Serial no Name alieve successors of the dead person Date of birth/ age as per birth certificate Relation to the dead person
Mahmuda Begum Wife
Halima Khatun Daughter
Rahima Begum Daughter
Shefali Begum Daughter
Khokon Son
Parvin Daughter
Kamrul Son
Shahin Son
Arif Son
The power has been given to send the deadbody of the dead person to the person bellow in favor of successors we gave signature with right minded, sound health and not having been solicitation from anyone else before witnesses.
Name of the person who will receive the deadbody National Identity Card No Relationb with the dead person Mobile no
Arif Hossain Son 01980491510
All of the people are requested to provide necessary help to the person given power:
Name of the successors who gave power Relation with the dead person National Identity No Signature/ tips
Mahmuda Begum Wife
Halima Khatun Daughter
Signature and witness of the witnesses: The person whom the power is given is personally known to me and gave signature before me.
Name of witnesses Number of National Identity Card No of the Witnesses Signature
1.
2.
Attatched seal and signature of the related union parishad chairman/ word commissioner/ pourashava mayer. As far I know the information given signature and tips is true, there is no any other successors of the dead person except mentioned above.
Date Signature and Seal Seal of Office
Jeddah Labor Wing: phone- 00966-012-6335082, Fax: 09660126675924, Mob: 00966507807130, Email:
(Logo)
Home Ministry
Name: Abdul Malek
Nationality: Bangladesh
Age: 56 Years
Date of birth: 30/11/1961
Hospital: MC ………………..
Regi no: 98815
Division: CCU
Form to Inform Dead News
The form is to be filled out as soon as the patient got dead
Profession Passport or work permit no:
Name of father of the dead person: Late Samed Ali Nationality: Bangladeshi
Name of mother of the dead person: Late Moyful Begum Date of birth: 30/11/1961
Home Address of dead person: Hazipur
Place of dead: KCO H (Hospital)
Diagnosis of admission: Chomolgic Vos
Gregorian Calender: 13/4/2017
Date of admission: 16/7/1438
Hizri Calender: ……………………………………….
Reason of Dead
First disease or reason which may direct cause of dead: Sudden pressure on the heart, weakness on muscle, rapid increase the percent of sugar in blood, increase of potassium in blood and low blood pressure.
(B) Other reason that may related to the dead but not related to it:
Date of dead: 19/7/1438
Time: hour min
Yes English date: 16/4/2017 Arabic date: 19/7/1438 Hizri
Name of doctor examined: …………………………………..
Signature: ……………………………………………..
Name and address of the relation with the dead person:
Name of doctor who treated: Fazle Mohammad
Signature: ……………………………………………………..
Official Stamp: ……………………………………………….
Doctor of the hospital: …………………………………..
Signature: ……………………………………………………….
Official Seal: …………………………………………………….
Royal Saudi Arab
Home Ministry,
Asir General Directorate Related to Health
Khamis Musaiyet General Hospital
Home Ministry
No: 4474/4141
Date: 2/4/1438 Hizri
Attested: …………………
Dead Report
Name of dead person Abdul malek Samed Ali Age: 56 Sex: Male
Nationality Bangladeshi English 1437- 48637
Date of got admitted in the hospital: 16/7/1438 Time: 5:30 Min
The person mentioned above made admitted in the hospital in that situation that sudden decrease in the heart and too much muscle weakness and very much increase of the sugar in the blood and traffin and increase of potassium and decrease of blood pressure.
Date of dead: 19/7/1438 Hizri
Time of dead: 2 AM in the morning
Reason of dead: As usual dead
Doctor Saleh
Doctor Fatema Signature: Illegible
Date: 6/7/1438
5072 Date: 19/7/1438 Hizri Report will be received on that
Name of mentioned doctor to resolve the issue of the subject: Please inform.
Thanking……….
Director, Khamis Al Mushaiyet General Hospital Ali Fahad
Successor approval and power letter to send deadbody in Bangladesh
Dead: Abdul Malek Father: Late Samed Ali Village: Hazipur (Malbari)
Post office: Police Station: Bhola District: Bhola
Dated 16/04/2017 got dead in the city Kamish Al Moshet in the Saudi Arabia. The alive successors are as bellow (In case of necessary separate successor letter can be attached.
Serial no Name alieve successors of the dead person Date of birth/ age as per birth certificate Relation to the dead person
Mahmuda Begum Wife
Halima Khatun Daughter
Rahima Begum Daughter
Shefali Begum Daughter
Khokon Son
Parvin Daughter
Kamrul Son
Shahin Son
Arif Son
The power has been given to send the deadbody of the dead person to the person bellow in favor of successors we gave signature with right minded, sound health and not having been solicitation from anyone else before witnesses.
Name of the person who will receive the deadbody National Identity Card No Relationb with the dead person Mobile no
Arif Hossain Son 01980491510
All of the people are requested to provide necessary help to the person given power:
Name of the successors who gave power Relation with the dead person National Identity No Signature/ tips
Mahmuda Begum Wife
Halima Khatun Daughter
Signature and witness of the witnesses: The person whom the power is given is personally known to me and gave signature before me.
Name of witnesses Number of National Identity Card No of the Witnesses Signature
1.
2.
Attatched seal and signature of the related union parishad chairman/ word commissioner/ pourashava mayer. As far I know the information given signature and tips is true, there is no any other successors of the dead person except mentioned above.
Date Signature and Seal Seal of Office
Jeddah Labor Wing: phone- 00966-012-6335082, Fax: 09660126675924, Mob: 00966507807130, Email:
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