[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 above named 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.