20 ___ yil «____» ____________________ soat _________________________ minutda
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________________________________________________________________________
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(jabrlanuvchining familiyasi, ismi, otasining ismi)
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bilan yuz bergan ________________________________________________________________
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(guruhiy, o‘lim bilan tugagan, oqibati og‘ir)
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________________________________________________________________________
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(kasbi, lavozimi, ish joyi,
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________________________________________________________________________
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korxona, yuqori turuvchi xo‘jalik organi, vazirlik,
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________________________________________________________________________
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xo‘jalik boshqaruvi organi nomi)
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________________________________________________________________________
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(buyruq)
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asosan quyidagi tarkibda tuzilgan komissiya:
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rais ________________________________________________________________________
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(F.I.Sh., lavozimi, ish joyi)
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________________________________________________________________________
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komissiya a’zolari: _____________________________________________________________
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(F.I.Sh., lavozimi, ish joyi)
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________________________________________________________________________
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taklif etilgan mutaxassislar ishtirokida__________________________________________
____________________________________________________________________________
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(F.I.Sh., lavozimi, ish joyi)
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20 ___ y. «________» ______________ dan 20 ___ y. «______» gacha mazkur baxtsiz hodisani maxsus tekshirdi va ushbu dalolatnomani tuzdi.
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