FORM 4
[Refer Rule 4 (1) (d)]
I, Dr. ……………….. possessing qualification of ……………….. registered as medical practitioner at Serial No. ………………… by the …………………… Medical Council, certify that –
(i) Shri. ………………… s/o Shri …………………… aged ……………
resident of ……………………… and Smt …………………D / o, w / o
Shri …………………………………… aged ………………….. resident of …………………. Are related to each other as spouse according to the
statement given by them and their statement has been confirmed by
means of following evidence before effecting the organ removal from
the body of the said Shri/ Smt. / Km. ……………………………………
(Applicable only in the cases where considered necessary).
OR
(ii) The clinical condition of Shri / Smt ……………………………………... mentioned above is such that recording of his /her statement is not
practicable.
Place …………………… Signature of Registered Medical Practitioner
Date …………………...
