(Chief or Primary cause)
(Contributing or secondary cause)
When was the illness diagnosed?
When in your opinion did the last illness become severe enough to prevent them from working? (Give details).
■ ■ ■ ■ ■
■ ■ If yes, for how long?
(Doctor’s name - please print)
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GROUP LIFE BENEFITS
ATTENDING PHYSICIAN’S CERTIFICATE OF DEATH
I hereby certify that
of employed by
died on the day of , 20 , from
What was the manner of death? Natural Accidental Suicide Homicide Undetermined
Did the deceased smoke? Yes No
Dated at this day of 20
This form should be completed in full by the Attending Physician.
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