Maternity Benefit Act,1961
FORM C: Death Certificate
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