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Physicians Certificate In Proof Of Death BWC-1163 - Ohio
| Physicians Certificate In Proof Of Death Form. This is a Ohio form and can be used in Medical Providers Workers Comp . |
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Better Workers' Compensation Built with you in mind. PHYSICIAN'S CERTIFICATE IN PROOF OF DEATH To be filled out by physician last in attendance on deceased. Claim No. Case of (Deceased) 1. 2. 3. 4. 5. Name of the deceased _____________________________________________________________ Sex ________ Age_____ Date of death ________________________________ Place of death_______________________________________________ Was coroner's inquest held?_________________________________________________________________________________ Was autopsy performed? ______By whom? ___________________________ Address ___________________________________ (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. 7. Were you medical advisor to the deceased during his terminal illness? _______________________________________________ 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 preexisting condition which caused death? ________________________________________________________________________ BWC-1163 (Rev. 8/16/2001) C-44 (Continued on reverse side) American LegalNet, Inc. www.FormsWorkflow.com (d) Reasons for your opinion 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. American LegalNet, Inc. www.FormsWorkflow.com
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