[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

Excerpt from Death Certificate

On 6/10/1360 [27 December 1981], sixth of Dey one thousand three hundred and sixty, number ----- Street ----- Division ----- City of Tehran, Tehran County, Mr. Jalal, surname Azizi, son of Azizollah and Bibi Jan, born in [redacted], birth certificate number [redacted], issued at [redacted], citizen of Region 3 Department of Civil Registration of Tehran County due to illness/accident ----- died and his death was registered in the Department of Civil Registration of Behesht-e Zahra, County number 163 64 –

6/11/1360 [26 January 1982].

This Excerpt from Death Certificate is submitted to Mr. Farzin Azizi, son of -----, without any scratch or alteration, as per his written request.  

Place of signature of representative and stamp of Tehran region, Department of Civil Registration of Behesht-e Zahra

6/11/1360 [26 January 1982]

[Signature over official stamp]