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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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