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Maternity Benefit Act,1961

FORM C: Death Certificate

[Rule 4(4)]

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

Maternity Benefit Act, 1961 Back

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