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DEATH CERTIFICATE

It is hereby certified that Sri. ________________________________________________ Son of

_____________________________________________________________ Ex-employee (Dept.

________________________________ Who has under my treatment) Whom, I Know, died of

(Disease) ______________________________________ on (Date) _________________ at

(Place) ____________________________________________________ dated ____________

Signature of the certifying Officer.

Designation: ________________

Note: This certificate should normally be issued by the Medical Office concerned. It may also be
issued by a private Practitioner or a Non – Gazetted Hakeem or vidye, in the case it should
invariably be counter signed by a Gazetted officer in service. As an alternative it may be issued
by any Gazetted officer in service who know the deceased.

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