[Form No. 19]

Report of Death (..... Day ..... Month ........ Year)	※ Please write after reading the guidelines on the back and, when required to select one option, please circle the number as follows "○".
① Deceased	Name	Korean or English		Sex	Resident Registration No.	-
Chinese characters		ꊱ Male ꊲ Female
Permanent domicile Address
Address		Householder․Relationship
Date and time of Death	..... Minute ..... Hour ..... Day ..... Month ........ Year (Time at place of death : According to the twenty-four hour clock)
Place of Death	Address	Beonji Ri Dong(Eup,Myeon) Gu(Gun) Si(Do)
Type of location	ꊱ House ꊲ Medical institution ꊳ Social welfare facilities (Home for the aged, Orphanage etc) ꊴ Public establishment (School, Playground etc) ꊵ Road ꊶ Business ▪ Service facilities (Store, Hotel etc) ꊷ Industrial facility ꊸ Farm (Rice paddy, field, barn, fishfarm) ꊹ D.O.A (Dead on arrival) Other
② Other facts
③ Reporter	Name	Seal or signature	Resident Registration No.	-
Relationship	ꊱ Cohabiting blood relative ꊲ Non-cohabiting blood relative ꊳ Cohabitant ꊴ Other (Head of institution /Administrator at place of death)	Relationship
Address		Tel.		E-Mail address
④ Submitter	Name		Resident Registration No.	-

※ The following information is needed for establishing population policies, so you are obliged to declare truth fully under Articles 32 and 33 of the Statistics Law. Please only write the truth your privacy will be strictly protected.

⑤ Cause of death		ꆲ	Immediate cause of death									Period from start of disease till death
		ꆳ	The cause of ꆲ
		ꆴ	The cause of ꆳ
		ꆵ	The cause of ꆴ
		Other related physical condition							Diagnostician					ꊱ Doctor ꊲ Oriental Doctor ꊳ Other
⑥ Type of death		ꊱ Death from an illness ꊲ Violent death (Accidental death) ꊳ Other and non-specific ( )
⑦ Details of violent death	Type of Accident	ꊱ Transportation(Traffic) ꊲ Poisoning ꊳ Death from a fall ꊴ Drowning ꊵ Fire ꊶ Other ( )								Intention or not			ꊱ Unintended accident ꊲ Suicide ꊳ Murder ꊴ Unsure
	Date of Accident	..... Minute ..... Hour ..... Day ..... Month ........ Year (According to the twenty-four hour clock)
	Region of Accident	ꊱ Same Si․Gun․Gu as current address ꊲ Other Si․Gun․Gu( Si․Do, Si․Gun․Gu) ꊳ Other (please state : )
	Place of Accident	ꊱ House ꊲ Medical institution ꊳ Social welfare facilities (Home for the aged, Orphanage etc) ꊴ Public establishment (School, Playground etc.) ꊵ Road ꊶ Business ▪ Service facilities (Store, Hotel etc) ꊷ Industrial facility ꊸ Farm (Rice paddy, field, barn, fishfarm) ꊹ Other
⑧ Deceased	Nationality			ꊱ Korean ꊲ Naturalized Korean citizen (Previous nationality : )
	Level of completed education			ꊱ Uneducated ꊲ Elementary school ꊳ Middle school ꊴ High school ꊵ University / College ꊶ Graduate school
	Occupation at time of accident or onset of disease							Marital status			ꊱ Single ꊲ Married ꊳ Divorced ꊴ Widowed

⑤ Cause of death		ꆲ	Immediate cause of death									Period from start of disease till death
		ꆳ	The cause of ꆲ
		ꆴ	The cause of ꆳ
		ꆵ	The cause of ꆴ
		Other related physical condition							Diagnostician					ꊱ Doctor ꊲ Oriental Doctor ꊳ Other
⑥ Type of death		ꊱ Death from an illness ꊲ Violent death (Accidental death) ꊳ Other and non-specific ( )
⑦ Details of violent death	Type of Accident	ꊱ Transportation(Traffic) ꊲ Poisoning ꊳ Death from a fall ꊴ Drowning ꊵ Fire ꊶ Other ( )								Intention or not			ꊱ Unintended accident ꊲ Suicide ꊳ Murder ꊴ Unsure
	Date of Accident	..... Minute ..... Hour ..... Day ..... Month ........ Year (According to the twenty-four hour clock)
	Region of Accident	ꊱ Same Si․Gun․Gu as current address ꊲ Other Si․Gun․Gu( Si․Do, Si․Gun․Gu) ꊳ Other (please state : )
	Place of Accident	ꊱ House ꊲ Medical institution ꊳ Social welfare facilities (Home for the aged, Orphanage etc) ꊴ Public establishment (School, Playground etc.) ꊵ Road ꊶ Business ▪ Service facilities (Store, Hotel etc) ꊷ Industrial facility ꊸ Farm (Rice paddy, field, barn, fishfarm) ꊹ Other
⑧ Deceased	Nationality			ꊱ Korean ꊲ Naturalized Korean citizen (Previous nationality : )
	Level of completed education			ꊱ Uneducated ꊲ Elementary school ꊳ Middle school ꊴ High school ꊵ University / College ꊶ Graduate school
	Occupation at time of accident or onset of disease							Marital status			ꊱ Single ꊲ Married ꊳ Divorced ꊴ Widowed

※ For official use only

읍면동접수	가족관계등록관서 송부		가족관계등록관서 접수 및 처리
	주민등록 번 호
	년 월 일(인)

Writing Method		※ You should submit to write a report of death.
① Deceased	□ Permanent domicile address: If a deceased is a foreigner, write the nationality. □ Resident registration number: If a deceased is a foreigner, please write an alien registration number(Domestic residence registration number or the date of birth). □ Date and time of death : <Example> PM 2hours 30minutes (X) →14hours 30minutes (O) Night 12hours 30minutes (X) → Next day 0hour 30minutes (O) □ If our people passed away abroad, write the dead time of local by A.D. (Anno Domini) and the solar calendar. When he/she died in period of summertime, please write the"summertime application" by the dead time of local. □ Section of deathplace : ꊱ The house include the houses of deceased, parent and relation. The others include a plane, a vessel, a train and etc. except example.
② The other facts	□ If a medical certificate of death(death certificate of dead) isn't attached, write the reason and requirements for a clear record on a certificate of family relations.
③ Reporter	□ Mark on applicable qualification with the "O" and ꊴ Other is included the administration of the deathplace and etc.
④ Submitter	□ Please write the submitter's(Regardless of the declarer is true or not) name and resident registration number.[An acceptable official in charge identify the submitter]
⑤ Cause of Death	□ Please write all causes of death on medical certificate of death(death certificate of dead) and the other body conditions.
⑥ Type of death	□ Please write a type of death on medical certificate of death(death certificate of dead) for reference. ꊲ violent death is relevant with accidental death and etc. except disease. In case of ꊳ other and non-specific, enter its contents concretely.
⑦ Clause of violent death	□ In case of an accidental death, write equally as certificate of death . If there aren't the recorded items, enter type of accident, a occurred region and place of accident concretely.
⑧ Deceased	□ Final graduated school of deceased should be recorded as standard all regular organizations which is approved by the Ministry of Education, Science and Technology. In(dropout) student of each school mark as "O" the relevant number of the graduated final school. <Example> Dropout of junior in college → Mark a high school of number ꊴ with "O" □ The occupation of deceased on occurring of disease(accident) has to be written thoroughly the occupation at occurrence of disease and accident of dead cause time. <Example> Employee → Detailer. department of business, ○○company (O)
Required Document(s)
1. Medical certificate or death certificate of deceased. 1 copy. 2. A written to be proved the fact of death. (If can't attach medical certificate or death certificate): One set of belows - Certificate of Death(Certificate of death to be written by head of Dong․Ri․Tong or more than two companions): If the certifier is companion(more than two persons), it should be attached one set of among their certificate of seal impression, copy of identification card, copy of driver's license, copy of passport and copy of public official card. If head of Dong․Ri․Tong is certifier, is enough to be proved by one person and in principle, it should be attached a written for certifying head of Dong․Ri․Tong . - Death certificate of government office or burial permit and approval. - Acception certificate for report of death (In case of death report at foreign government office) ※ Below No. 3 can be omitted if the contents is checked by computer at office of family relation registration. 3. Basic certificate of the deceased's family relation register. 1 set. 4. Identification. [In accordance with Article 23 of the established rule for family relation register] - In case of reporter's attendance : Identification card - In case of submitter's attendance : Copy of reporter's identification card, a submitter's identification card - In case of postal submission : Copy of reporter's identification card. 5. If a deceased is foreigner : Written(passport or alien registration card) for certifying the nationality.
※ Information of limited approval and inheritance waiver of property		* This information is the contents regardless of a death report. Please ask detail information to public service center of family or district court.
1. Meaning : Limited approval - To approve an inheritance within limit of the inherited property. Waiver - To waive the succession of all right and obligation about inheritance property 2. Method : Limited approval - Please report to family court with inheritance property list. Waiver - Please report to family court the waiver. 3. Period of report : Within 3 months from the day to be known the start of inheritance (In accordance with the Proviso of Article 1019, Paragraph 1 of the Civil Law) If the heir don't know that the inherited debt is over the inherited property during period of report without gross negligence and if he approved as simple(Include the case of simple approval in accordance with Article 1026 section 1 and 2 of civil law) can approve as limit within 3 months from day to be known the fact. 4. Jurisdiction : Competent court in starting region of inheritance [(Last) address of inheritee]

Report of Death

(사망신고서)

① Deceased  (사망자)

￭ Please write a deceased's Korean or English name and in Chinese characters.

(사망자의 한글 이름과 한자로 쓰세요.)

￭ Please write a deceased's sex and resident registration number.

(사망자의 성별과 주민등록번호를 쓰세요.)

□ Resident registration number  (주민등록번호)

If a deceased is a foreigner, please write an alien registration number.

(Domestic residency registration number or the date of birth)

(해당자가 외국인인 경우에는 외국인 등록번호(국내거소신고번호 또는 출생연월일)를

기재합니다.)

￭ Please write a deceased's Permanent domicile address.

(사망자의 등록 기준지를 쓰세요.)

□ Permanent domicile address: (등록 기준지)

If a deceased is a foreigner, please write the nationality.

(사망자가 외국인인 경우에는 그 등록기준지에 국적을 기재해 주세요.)

￭ Please write a deceased's address. (사망자의 주소를 쓰세요.)

￭ Please write the relations between a householder and a deceased.

(세대주 관계와 사망자의 관계를 쓰세요.)

￭ Please write the date and time at place of death according to the twenty-four

hour clock.

(사망지의 시간을 24시각제로 기재해 주세요.)

□ Date and time of death  (사망 일시)

<Example> PM 2hours 30minutes (X) →14hours 30minutes (O)

Night 1hour 30minutes (X) → Next day 0hour 30minutes (O).

□ If Korea citizens passed away overseas, please write the dead time of local by

A.D.(Anno Domini) and the solar calendar. And when he/she died a period of

summertime, please write the"period of summertime" by the dead time of

local.

(우리나라 국민이 외국에서 사망한 경우, 현지 사망시각을 서기 및 태양력으로

기재하시고 서머타임 기간 중에 사망하였다면 사망자 시각 옆에 "서머타임 적용"

이라고 표시하세요.)

￭ Please write an address of deathplace

(사망지 주소를 기재해주세요.)

￭ Please select the deathplace out of following number

(아래의 숫자 중 사망지를 선택해주세요.)

※ Classification of deathplace

ꊱ House 주택

※ The house include the house of deceased, parent and relative.

(주택은 사망 장소가 사망자의 집이거나 부모. 친척 등의 집에서 사망한 경우를

포함합니다.)

ꊲ Medical institution 의료기관

ꊳ Social welfare institution [Home for the aged, Orphanage etc]

(사회복지시설 [양로원, 고아원 등])

ꊴ Public establishment(School, Playground etc) (공공시설(학교, 운동장 등))

ꊵ Road  도로

ꊶ Business ▪ Service facilities.(Store, Hotel etc) 상업 ▪ 서비스시설 (상점, 호텔 등)

ꊷ Industrial facility 산업장

ꊸ Farm(Rice paddy, field, barn, fishfarm) 농장 (논밭, 축사, 양식장 등)

ꊹ D.O.A (Dead on arrival) 병원 이송 중 사망

Other (               )  기타

※ Please write the place included a plane, a vessel, a train etc except above

example. (기타는 예시 외에 비행기, 선박, 기차 등을 포함합니다.)

② Other facts

￭ Please write the reason that a medical certificate of death is not affixed.

(사망진단서를 첨부하지 않은 이유를 기재해 주세요.)

※ If a medical certificate of death is not affixed, please write the reason and

the special requirements for a clear record on a certificate of family relations.

(사망진단서(시체검안서) 미 첨부 시 그 사유 등 가족 관계 등록부에 기록을

분명히 하는데 특히 필요한 사항을 기재한다.)

③ Reporter

￭ Please write the reporter's name, sign or seal and resident registration number.

(신고인의 성명, 사인이나 도장을 찍고 주민등록번호를 기재해주세요.)

￭ Please select the relationship with reporter out of following number.

(아래의 번호 중 신청인의 자격을 선택해 주세요.)

ꊱ Cohabiting relative 동거 친족  ꊲ Non-cohabiting blood relative 비동거 친족

ꊳ Cohabitant 동거자

ꊴ Other [Head of Protective institution/Director at place of death, etc.]

(기타 [보호 시설장/ 사망 장소 관리장 등])

￭ Please write the relations between the applicant and deceased.

(신고인과 사망자와의 관계를 기재해주세요.)

￭ Please write the reporter's address, phone number and e-mail.

(신고인의 주소, 전화번호, 이메일을 기재해 주세요.)

※ Please mark the applicable relationship with the "O" and other includes the

management chief of the deathplace, etc.

(해당되는 자격에 “○”으로 표시하시고 기타는 사망 장소를 관리하는 자 등이

포함됩니다.)

④ Submitter  제출인

￭ Please write a submitter's name and resident registration number.

(제출인의 성별과 주민등록번호를 쓰세요.)

※ (Regardless of the declarer is true or not) 신고인 여부와 관계없음

[An acceptable official in charge identify the submitter].

([접수한 담당 공무원은 제출인의 신원을 확인한다.])

□ The following information is needed for establishing population policies, so you

are obliged to declare truth fully under Articles 32 and 33 of 「The Statistics

Law」. Please only write the truth your privacy will be strictly protected.

(다음은 국가의 인구정책 수립에 필요한 자료로「통계법」제32조 및 제33조에

의하여 성실응답 의무가 있으며 개인의 비밀사항이 철저히 보호되므로 사실대로

기입하여 주시기 바랍니다.)

⑤ The Cause of Death 사망의 원인

￭ Please write a dead cause as a medical certificate of death.

(사망자의 직접적인 사망 원인을 기재해 주세요.)

ꆲ Immediate cause of death.  사망의 직접적인 원인

ꆳ The cause of ꆲ            ꆲ 의 원인

ꆴ The cause of ꆳ            ꆳ 의 원인

ꆵ The cause of ꆴ            ꆴ 의 원인

□ Please write the same that a medical certificate of death is all cause of death

and another physical condition.

(사망진단서(시체검안서)에 기재된 모든 사망의 원인 및 그 밖의 신체상황 내용을

동일하게 기재합니다.)

※ Period from start of disease till death.  발병부터 사망까지 기간

￭ Please write the period from start of disease till death.

(사망자의 병이 발병부터 사망까지 기간을 기재해주세요.)

※ Another physical condition

￭ Please write another physical condition of deceased as a medical certificate of death.

(사망자의 또 다른 신체상황을 기재해 주세요.)

￭ Please select the diagnosable doctor out of following number.

(아래의 번호 중 사망자의 진단자를 선택해 주세요.)

※ Diagnostician  진단자

ꊱ Doctor 의사  ꊲ Oriental Doctor 한의사  ꊳ Other  기타

⑥ Type of Death  (사망의 종류)

￭ Please select the type of death out of following number.

ꊱ Death from an illness 병사

ꊲ Violent death [Accidental death, etc]  외인사 (사고사, 등)

ꊳ Other and non-specific  기타 및 불상

□ Please write type of death on certificate of death as reference and a violent death of

number ꊲ includes only accidental death except disease. Also if you select No

ꊳ, please write its contents concretely.

(사망 진단서(시체검안서)에 기재된 사망의 종류는 사망진단서를 참고로 기재하고,

사고사는 진단서상에 외인사에 해당하며, 기타인 경우 그 내용을 구체적으로

기재합니다.)

⑦ Details of a violent death  (외인사 사항)

￭ Please select details of a violent death out of following number.

(아래 번호 중 외인사 사항을 선택해 주세요.)

※ Type of an accident  (사고 종류)

ꊱ Transportation(Traffic)  운수(교통)    ꊲ Poisoning  중독

ꊳ Death from a fall  추락             ꊴ Drowning  익사

ꊵ Fire  화재                          ꊶ Other  기타

※ Intentional or not  (의도성 여부)

ꊱ Unintended accident  비의도적 사고   ꊲ Suicide  자살

ꊳ Murder  (타살)                      ꊴ Unsure  미상

※ Date and time of accident  (사고 일시)

￭ Please write the date and time of accident according to twenty-four hour

clock.

(사망 일시를 24시각제로 기재해 주세요.)

※ Region of accident  사고 지역

￭ Please select the region of accident out of following number.

(아래의 번호 중에 사고 지역을 선택해 주세요.)

ꊱ A city, country and district like the current address (현주소지와 같은 시군구)

ꊲ Other city, country and district (다른 시군구)

￭ If you select number 2, please write the concrete city, provinces, country,

district.

(만약 2번을 선택했다면 자세한 시, 도, 군, 구 기재해주세요.)

(         City/provinces,         country/district)

ꊳ Other  기타

※ Place of accident  (사고 장소)

￭ Please select the place of accident out of following number.

(아래의 번호 중에 사고 장소를 선택해 주세요.)

ꊱ House  주택        ꊲ Medical institution  의료 시설

ꊳ Social welfare institution [Home for the aged, Orphanage etc]

(사회 복지 시설 [양로원, 고아원 등])

ꊴ Public establishment(School, Playground etc.)  공공시설 (학교, 운동장 등)

ꊵ Road  도로

ꊶ Business ▪ Service facilities(Store, Hotel etc)  상업 ▪ 서비스 시설 (상점, 호텔 등)

ꊷ Industrial facility (산업장)

ꊸ Farm(Rice paddy, field, barn, fishfarm)  농장 (논밭, 축사, 양식장 등)

ꊹ D.O.A (Dead on arrival).  병원 이송 중 사망

Other  기타

□ In case of an accidental death write as certificate of death equally. If it is not

recorded the contents, please write type of accident, region and place of

accidental occurrence concretely.

(사고사로 사망한 경우에는 사망 진단서와 동일하게 기재한다. 기재할 내용이

없는 경우 사고의 종류, 사고 발생지역 및 장소를 구체적으로 기재해 주세요.)

⑧ Deceased  사망자

※ Nationality  국적

￭ Please select the nationality of deceased out of following number.

(아래의 번호 중 사망자의 국적을 선택해 주세요.)

ꊱ Korean  한국인

ꊲ Naturalized Korean (Previous nationality :     ) 귀화한 한국인 (이전의 국적 :   )

￭ Please select the graduate school out of following number.

(아래의 번호 중 최종 졸업 학교를 선택해 주세요.)

ꊱ Uneducated 무학             ꊲ Elementary school  초등학교

ꊳ Middle school  중학교        ꊴ High school  고등학교

ꊵ University /College  대학(교)  ꊶ Graduate school  대학원 이상

□ The graduate school of deceased should be recorded all formal organizations

that Ministry of Education, Science and Technology recognizes. And a student

(dropout)of each school mark the relevant number of the last graduation

school with "O".

(사망자의 최종 졸업 학교는 교육과학기술부장관이 인정하는 모든 정규기관을

기준으로 기재되어야 하고, 각급 학교의 재학(중퇴)자는 졸업한 최종학교의       해당 번호에○표시를 합니다.)

<Example> Dropout of junior in college → Mark a high school of number 4 with "O"

(<예시> 대학교 3학년 중퇴 → 4번 고등학교에 “O" 표시)

※ Then occupation on starting of disease(accident)  발병(사고) 당시 직업

￭ Please write the occupation on starting of disease(accident).

(발병(사고) 당시의 직업을 기재해 주세요.)

□ The occupation on starting of disease(accident) of deceased is written

concretely the occupation on occurrence of disease or accident make to die.

(사망자의 발병(사고)당시 직업은 사망의 원인이 되는 질병 또는 사고가 발생 한 때의

직업을 구체적으로 기재합니다.)

<Example>  Employee  → Detailer. department of business, ○○company (ㅇ).

(<예시> 회사원(×) → ○○회사 영업부 판촉사원(○)

공무원(×)→ ○○ 청 건축허가 업무담당(○))

※ Marital status  혼인 상태

ꊱ Single  미혼         ꊲ Married  배우자 있음

ꊳ Divorced  이혼      ꊴ Widowed  사별

□ Required Document(s)

1. Certificate of Death or Medical certificate of death about deceased 1 copy

(사망자에 대한 진단서나 검안서 1부.)

2. Document(s) be proved fact of death (사망의 사실을 증명할 만한 서면)

(If a medical certificate of death can not be affixed) : 1 copy out of following)

(진단서나 검안서를 첨부할 수 없을 때): 아래 중 1부.

￭ Certificate of Death (Head of Dong and Ri or neighborhood more than 2

people recorded certificate of death). If the provable people are neighborhood

(more than 2 people), it should be affixed 1 copy among their certificate of

seal impression, copy of resident register, copy of a driving license, copy of

passport, identification of public official should be affixed. In event of head         of Dong/Ri is enough to prove just 1 person, it should be affixed the provable

document of head of Dong/Ri in principle.

(사망증명서(동·리·통장 또는 인우 2명 이상이 작성한 사망증명서) : 증명인이        인우인(2명 이상)인 경우에는 증명인의 인감증명서, 주민등록증사본, 운전 면허증        사본, 여권사본, 공무원증사본 중 1부 첨부하여야 하며, 증명인이 동·리·통장일

때에는 1명의 증명으로 족하고 원칙적으로 동·리·통장임을 증명하는 서면 첨부해야 한다.)

￭ Certificate of death in government office or a certificate of burial

(관공서의 사망증명서 또는 매장인허증)

￭ Certificate for report process of death  (사망신고수리증명서)

(In case of the report in government office of overseas)

(외국관공서에 사망 신고한 경우)

※ Under 3 clause can be omitted if the department in charge of family relation

certification can check this information.

(아래 3항은 가족관계등록관서에서 전산으로 그 내용을 확인할 수 있는 경우

첨부를 생략합니다.)

3. Basic certificate of the deceased's a family relation register 1 copy

(사망자의 가족관계등록부의 기본증명서 1통)

4. Identification  (신분확인)

[In accordance with Article 23 in a certificate of family relations register]

([가족관계등록예규 제23호에 의함])

￭ Application by visit : Certificate of identification

(신고인이 출석한 경우 : 신분증명서)

￭ Submitter by visit : Copy of an applicant's identification certificate, a submitter's                          identification certificate

(제출인이 출석한 경우 : 신고인의 신분증명서 사본 및 제출인의 신분증명서)

￭ Application by mail : Copy of an applicant's identification certificate

(우편제출의 경우 : 신고인의 신분증명서 사본)

5. If a deceased is foreigner, it should be submitted writing(passport or alien

registration card) copy about nationality.

(사망자가 외국인이라면 국적에 관한 서면 (여권 또는 외국인 등록증) 사본 제출

해야 한다.)