FORM ‘E’
[See Rule 5(4)]
This is to certify that Smt. ______________ wife/daughter of ____________ employed
in ________________________ (name of the establishment) expired on ____________
before/during/after confinement. The child died on _______________ survives her.
Dated___________________
Signature, qualification and
Designation of Medical Officer/
Medical Practitioner.
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