No. 6.—Medical Certificate claiming Funeral Allowance.

I, _____ hereby certify that _____ aged _____ years, late of _____ died on the _____ day of _____ 18 _____, and that I consider his (or her) death to have been caused by _____ (or the verdict was, as the case may be). _____ Dated this _____ day of _____ 18 _____ Tent Surgeon (or legally-qualified Medical Practitioner, residing at _____, or Coroner, as the case may be).