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___
Insurance Medical Officer
(Rubber stamp or name in block letters)
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.