(TRANSLATION)
Thor Ror 4 Part 1
Official Emblem
Application No.
DEATH CERTIFICATE
Registration Office: No.
1. The Deceased 1.1 Name and Surname:
1.2 Identification No:
1.3 Sex:
1.4 Age:
years
1.5 Nationality:
1.6 Occupation:
1.7 Marital Status:
1.8 Address:
2.Particulars of Death 2.1 Date of Death: at hrs. 2.2 Person Giving Treatment before Death:
2.3 Death Certifying Document:
No. 2.4 Cause of Death:
3. Place of Death 3.1 Name and Address of Place of Death:
3.2 Duration of Stay at the Place of Death:
4. The Deceased’s Parents 4.1 Mother’s Name-Surname: 4.2 Identification No. of Mother:
4.3 Father’s Name- Surname: 4.4 Identification No. of Father:
5. Death Notifying
Person 5.1 Name and Surname:
5.2 Identification No.
5.3 Address:
5.4 Relationship to the Deceased:
6. Corpse 6.1 Corpse Arrangement:
6.2 Location:
7. Death Acknowledging Document: 8. Death Acknowledging Date :
Signed: …….................................
( )
Death Notifying Person
Signed:.......................................
( )
Performing Officer
Signed: …….............................
( )
Death Acknowledging Registrar
Change of Corpse Arrangement
Signed………………Registrar……………………..
Change Acknowledging Person
Additional Records:
Certified Correct Translation
( )