[PROVISIONAL TRANSLATION FROM PERSIAN]

 

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

 

[Emblem]

Islamic Republic of Iran

Ministry of the Interior

National Organization for Civil Registration

F/12

 

Copy of the death certificate

 

On-----27th of Esfand year 1370 Shamsi [Solar calendar] [17 March 1992]

 

The house/shop number-----street-----suburb----the city of: Tehran, District-----village-----Tehran County

Mr./Mrs:. Bahman, family name: Samandari, the son of: Azizollah and Bahiyyeh, born on: [redacted]

With the birth certificate number: [redacted] issued in city/town/village-----part of: Tehran

Subordinate to: District 3 of the office of Registry of the Tehran County

Died due to illness/accident: suicide and his death has been registered in the registry of the dead of 1371[1992] of District 1 subordinate to the office of Registry of Beheshteh Zahra county number 14042

 

This copy of the brief of the death has been served to Mr./Mrs. Samandari, Bahman’s son/daughter based on the written request, without any marks or scratches and in perfect condition.

 

The signature of the representative and the stamp of the city district of the office of Registry in Shemiran County.

 

Signature over the official stamp