Questionnaire Text

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Deaths in the last 12 months
[] No
[] Yes

If yes, how many? _

First and last name of deceased ____
Sex of deceased ____
Age at death ____
Questionnaire instructions view entire document:  text  image

Deaths during the last 12 months

This question, located at the top of the household form, concerns the number of deaths that happened in the household during the last 12 months (since December 1984). Put a cross in the box marked Yes or No according to whether or not a death happened in the household.

If Yes, specify the full name, sex and age (in years, months or days) of the deceased at the time of their death.