[PROVISIONAL TRANSLATION FROM PERSIAN]

 

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

 

Islamic Republic of Iran

National Organization for Civil Registration

 

[Emblem]

Certificate of death

670333 F-70

 

Particulars of the deceased

Name: Bahman

Last name: Samandari

Gender: Male

National identification number: [redacted]

Birth certificate number: [redacted]

Date of Birth: 17 Aban 1318 [9 November 1939]

Issued in: Tehran

Division: 3

Name of father: Azizollah

Name of mother: Bahiyyeh

Marital status: -----

Occupation: -----

Education: -----

Particulars of death

Date: 27 Esfand 1370 [17 March 1992]

Location: Tehran

Reason: Hanged

Registration number: 14402

Location document was prepared: Behesht-e-Zahra, Tehran 22 Farvardin 1371 [11 April 1992]

Registration date: 22 Farvardin 1371 [11 April 1992]

Comments: -----

Received by

This certificate was issued and delivered based on the request of Mr./Mrs., son /daughter of -----.

Certificate issued by

Office of Civil Registration: Tehran Central

Name and surname the officer: Amiri

Date and stamp:

[Stamp of Office of Civil Registration, Central Region of Tehran]

[Signature]