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FORM 23: MATERNITY BENEFIT Regulations 88 and 89 CERTIFICATE OF CONFINEMENT OR MISCARRIAGE Signature or thumb impression of the insured woman Employer's Code No Stamp of the dispensary Book No ________ Serial No ________ I certify that I attended, ___________________________________________ Insurance no ______________ in connection with her confinement/ miscarriage at _____ (address) and that she was there delivered of a child on the _________ day of______________19__ Signature of midwife, if any. Signature or counter-signature of Insurance Medical Officer (Rubber stamp or name in block letters) Any other remarks ______________________________________ | |||||
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