defence services regulations pension regulations for the army

109APPENDIX –IXANNEXURE – II(Referred to Regulations 35,43)STATEMENT OF CLAIMANT IN CASE OF DEATH AFTER DISCHARGE OR ATHOME WHILE ON LEAVE WHEN THE DECEASED WAS NOT TREATED BY AQUALIFIED MEDICAL PRACTIONERStatement of Shri/Smt-------------------------------------------------------------------------------Father/Mother/Widow of Rank-------------------------------------------------No.---------------Name ----------------------------------------------------------------of -------------------------------claimant of family/dependant pension-------------------------------------------------------------1. Date and time of death:2. Name of disease, which caused death:3. Details of medical treatment received by the deceased since his discharge from service:4. The disease causing death started on (here give the date, if known, otherwise indicatethe approximate month & Year)5. Signs and symptoms of the disease causing death are given below (here give briefdetails like location and nature of pain, breathing difficulties, inflammations, stomachdisorders, loss of consciousness, fever etc. and any other peculiar symptoms).6. He was not treated by any medical practitioner as-----------------------------------------(here give reason why no medical treatment was given)Place --------------------Signature of thumb impression of theDate--------------------claimantWe certify that the above facts are known to us personally and that they arecorrect.(i)(ii)Signature 1 st witness(Name & Address)Signature 2 nd witness(Name & Address)Place--------------------Date --------------------Pension Regulations for the Army, Part II (2008)