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 above named 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 _______________________
