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)

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