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VOLUME – I CHAPTER 2

108

APPENDIX –IX
ANNEXURE – I

(Referred to Regulations 35,43)

FORM OF DEATH CERTIFICATE AND STATEMENT OF CLAIMANT

FORM OF DEATH CERTIFICATE IN CASES OF DEATH AFTER DISCHARGE OR
AT HOME WHILE ON LEAVE WHEN THE DECEASED WAS TREATED BY A

QUALIFIED MEDICAL PRACTITIONER

DEATH CERTIFICATE

Name of the deceased:

Date of onset of the fatal disease:

Name, Nature and symptoms of the disease:
Duration of illness:

Particulars of treatment received from the medical practitioner:
Information (if known) regarding medical treatment received by the deceased since his

discharge from service:
Time and date of death:

Signature of the Medical Practitioner
Designation

Regd. No

Place----------------- .
Date-----------------

Pension Regulations for the Army, Part II (2008)

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