Certificate Of Death/Disablement Of Military/Paramilitary Personnel
Certified that Mr./Ms.__________________________________, is the son/daughter/spouse of Shri ____________________________ rank __________________________.
Shri _____________________________ was killed/disabled to the extent of 50% or more, in action/not-in- action but otherwise, while being in service, on _________________(date). His death/disability is entirely attributable to military service.
Shri ___________________________ was boarded out of service on ____________ (date) with disability attributable to military service.*
| Date | Seal | Signature of Authorized Officer |
*(strike out this sentence if not applicable)