FORM 24B: MATERNITY BENEFIT DEATH CERTIFICATE Regulation 89A Book No _____________ Serial No _____________ Stamp of the dispensary Name of the deceased insured woman ____________ wife/daughter of _____________ Insurance No _______ I certify that in my opinion the abovenamed deceased insured woman died on ________ 19___ as a result of ________ during her confinement* /during a period of ________ weeks immediately following her confinement,* leaving behind the child. In my opinion, the said child also died on ____ 19 ______ as a result of _________________ I had been attending her */ and also her said child for providing medical benefit before her/her said child's death and I attended her for the last time on _____19 ___ and her said child for the last time _____________ 19___ Signature Insurance Medical Officer (Rubber stamp or name in block letters) Date ________ Any other remarks by the Medical Officer _________________________________ Notes: (1) Delete whichever is not applicable. (2) The language may be suitably amended if the Insurance Medical Officer had not attended the deceased person before her/her child's death. | 
