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Physicians Certificate In Proof Of Death Form. This is a Ohio form and can be use in Medical Providers Workers Comp.
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Tags: Physicians Certificate In Proof Of Death, BWC-1163, Ohio Workers Comp, Medical Providers
Physician's Certificate
in Proof of Death
The physician who last attended the deceased completes this form.
Claim No.
Case of
(Deceased)
1. Name of the deceased: _________________________________________________________________ Sex: __________ Age:__________
2. Date of death: ________________________________ Place of death:_________________________________________________________
3. Was coroner's inquest held?___________________________________________________________________________________________
4. Was autopsy performed? ________ By whom? ______________________________ Address: ______________________________________
5. (a) Diagnoses and descriptions of all injuries, diseases and illnesses for which you have examined or treated the deceased.
Include clinical findings:
(b) Dates or periods when you examined or treated the deceased:
6. Were you medical advisor to the deceased during his terminal illness?
7. Give names and addresses of other physicians who examined or treated deceased:
8. (a) Principal causes of death:
(b) Related and contributory causes of death:
9. Were you furnished with history of injury or occupational disease as alleged?
By whom? ______________________________________________ When?
Report history as obtained:
10. In your opinion was there a causal relationship between decedent's death and the alleged injury or occupational disease?
(a) Direct? _______________ (b) Indirect? _____________________ (c) Did the injury or occupational disease aggravate a pre-existing
condition which caused death?
(d) Reasons for your opinion:
(Continued on reverse side)
BWC-1163 (Rev. 2/15/2005)
C-44
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Dated this _________________ day of ______________________________________________________________________ , ________________
(Attending Physician)
Degree:_________________________ Year: ________________________ College:_____________________________
Affidavit
State of Ohio, ________________________________ County, ss:
On this _______________ day of _____________________________________________________ , A.D. ________________ , personally appeared
before me, the above named __________________________________________________________, physician in good standing, and made oath that
the answers by him above made and subscribed are true and that he has with held no material facts regarding the decedent's illness and death.
(Title of officer taking acknowledgment)
NOTE: Official taking acknowledgment should see that form and oath are properly filled out.
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