An official death certificate was issued for an ex-employee who died of an unspecified disease on a specific date at a given location. The certifying medical officer signed the document, providing their designation. The certificate is normally issued by the relevant medical office but can also be issued by a private practitioner if countersigned by a gazetted officer familiar with the deceased.

1. DEATH CERTIFICATE
It is hereby certified that Sri. ________________________________________________ Son of
_____________________________________________________________ Ex-employee (Dept.
________________________________ Who has under my treatment) Whom, I Know, died of
(Disease) ______________________________________ on (Date) _________________ at
(Place) ____________________________________________________ dated ____________
Signature of the certifying Officer.
Designation: ________________
Note: This certificate should normally be issued by the Medical Office concerned. It may also be
issued by a private Practitioner or a Non – Gazetted Hakeem or vidye, in the case it should
invariably be counter signed by a Gazetted officer in service. As an alternative it may be issued
by any Gazetted officer in service who know the deceased.