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FORM 17: DEPENDANTS' OR FUNERAL BENEFIT

Regulations 79 and 95C

DEATH CERTIFICATE

Book No ___________

Serial No ____________

Stamp of the dispensary

Name of the deceased insured person _________________________________

son/wife/daughter of _______________

Insurance No ____________________

I certify that in my opinion the abovenamed deceased insured person died on the day of __________ 19 __,as a result of an injury. 55[I had been attending him/her for providing medical benefit before his/her death and I attended him/her for the last time on the _____ day of ___ 19___

Signature ___________

Insurance Medical Officer

(Rubber stamp or name in block letters)

Date ________

Any other remarks by the Medical Officer _______________________

 

 

 

 

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