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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    |
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