This is to certify that Smt. ____________ wife/ daughter of ___________ employed in _________ (name of 3[mine or circus]) expired on _________ before/during/after confinement. The child died on __________ /survives her.
Signature, qualifications and designation of
Date _________ Medical Officer/Medical Practitioner 3 Inserted by GSR 70(E), dated 31st. January, 1996, w.e.f.1st. February, 1996.
