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flrGT dqR frdrff frBl5 z BHARAT sANcHAR NrcAM LrMrrED

(gffT-I S{dFl:t EFT 5q?F-fr) / (Govt. oflndiaundertaking)

ffFrgcitrF qFiqR iDT iFTqtil-q ,/ O/o General Manager, Ahmednagar -414 001
3tFrt?ner fr srqr EF'I rJrTurq:r trr{Flrao - fr-t )
Certifi cate for Hospital ization (An n ex u re-D- 1 )

ql d"TI 3'r$kTrT fr :rqqn h frq ffi go t, t$ ?{rrd di sr{r qrqr

To be completed in the case of patients who are admitted in hospital for treatment

fr(rgqrd(rd h EFrqttrq dm6qoaffzffi

frqRzqF /94/ gfiza,Til/ fraraffzffi 6i T6
Fffrurq{ fi+qr srdr Ft
Certificate granted to MrsAvIr husband / wife / son / daughter /
mother I father Mrs/IvIr employed in the offrce of

C d.z I or. (tr.{dRr rfrrFfd ofar ( l.F',/herebyceftirythat
rirTl o,1 3fi{rcnd C fr. qn rS fi+qr enr
The patient was admitted to hospital on

. tfi et sqqn h 3iild-d EE d. fr en gitr trfr 6f fi am fr nr$ e-qrf{fi

nrh qqreq / ftfr 6I rb{R Rft fr fdnq lq sml+o tfrr
The patient has under treatment at ward no. and that the mentioned medicines prescribed by nre in
this connection were essential for the recovery / prevention of serious beterioriation in the condition of the patient.

. ltfr t frf.rfi t u qr 3itr E. fr.

The patient is / was suffering from and is / was under treatment from

e erffit, ffil dE 3ilG R{r+,r Td Erqt s. 3rFraz[iF' qr 3it{ g1 qlraet il'

3I{.{R lrrcuarazffi tFT ;Trfr) fr loor rrqrt
The X-ray, laboratory tests etc. for which an expenditure of Rs. was incuned were necessary and
were undertaken on my advice at (name of hospital/laboratory).

3r€tlcneT 6 affd S wTfr ftltnd 3{MT h' Owrafi sit{ qqpTET

Sign. and Design. Of the medical officer incharge of the case at the hospital

{{{ *6t h' grq ,/ with rubber stamp t,;,

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