CSC FORM 41

PH{LIFPTHE CIflL SERVICI

MEOICAT CERTITICOTE
I hereby waive all rights and privileges pertaining to profbssional confidence between physician and patients,
and the physician accomplishing this form is authorized to answer in detail question containld herein.

Signature of Patient

Attending physician should fill in blank below, every detail should be answer to avoid delay in action ari
application for leave submitted byfhe patient
( PatientS
of the department on account of illness I do hereby cerlify that
I was the applicant's actual attending physician from '}Ato 20
inclusive and from my professional lirror,l'ledge of the case the foilowing statements are submitted as contempleted
byprOvision of Section 8 of Civil Service )ffV.

Name of disease or disability

Nature of disease or disabilify

{ Under this heading, in addition to giving fully the etiology of the disease or diability, the
ETIOI'OGY { physician must either state in Language of the Executive Order. "There are no indications
t whatever that the disease name was due to immoral or vicious habits" or give the indication.

HISTORY

DESCRIPTION

exmination
.A Laboratory test in this case
The applicant was confined to herAris honre/hospital from 20
2A--.
I HEREBY CERTIFY that the above statement are complete and true in every detail, in that in consequence
of the disease or disability above specified the applicant was ill unable to be on duty on aecount of illness from
2A_fi 20 iriclusive and that his/her claim is meritorius,
(Signature) M.D.
Doc. Stamp (P.O. Address)
-_.*
20