I certify that in my opinion the above named deceased insured person by JKqlzrL

VIEWS: 5 PAGES: 1

									                                            FORM 17
                                DEPENDENTS’ OR FUNERAL BENEFIT
                                     [ Regulation 79 and 95C]
                                      DEATH CERTIFICATE
Book No…….
Serial No……                                                       Stamp of the dispensary Name of the 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
                                               1
………..19…………, as a result of an injury. [ I had been attending him/her for providing medical benefit 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)
Any other remarks by the Medical Officer …………………………………………………………

								
To top