[See rule 4(4)]
This is to certify that Smt….. wife/daughter of….. employed in…… (name of 1[mine or circus]) expired on ……before/during/after confinement. The child died on…/survives her.
Ins. by G.S.R. 70(E), dated 31st January, 1996 (w.e.f. 31-1-1996).
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