[PROVISIONAL TRANSLATION FROM PERSIAN]

 

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

 

[Emblem]

Islamic Republic of Iran

Tehran Municipality

Number: 30862

Date: 7 Dey 1360 [28 December 1981]

Date of passing: 6 Dey 1360 [27 December 1981]

Behesht-e Zahra[1]

Passing Notice

Receipt Number:

Amount: ----- rials

 

Name of the deceased: Ghodratollah, Surname: Rowhani, Father’s Name: Fazlollah

Mother’s Name: -----, Identification Number: ------, Issued from: -------, Date of birth:

Age: ------, Occupation: --------, Citizenship: Iranian, Place of death: Evin, Tehran

Street: -------, Lane: --------, House Number: -------, Type of illness: Bullet wound, Attending Physician or Hospital: Office of the Prosecutor of Tehran, Place of Burial: Khorasan Road

Nominator: Mr. / Mrs. ------, Surname: -----, Identification Number: ------, Issued from: Revolutionary Court, Residing District: -----, Street: ------, Lane: Islami Markaz, House Number: -------

Occupation: ------, Place of Work: ------

 

Signature of the Nominator:

Signature of the issuer: [Signature]

 

[Handwritten Note: Number and date at the end of this page]

14737

10 Dey 1360 [31 December 1981]

 

[1] [the name of Tehran Cemetery]