[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

The Personal Status Registration Office

Extract from death certificate

 

On 6/10/1360 [27 December 1981] house … .street … ally … city: Tehran, village … county … Mr. Mahmoud surname: Majzoub, son of Esmail and Ghamar, born in 1309 [1930], identification number [redacted], issued in Malayer, part of rural district … area 1, birth registry of the Malayer county, has died of … illness … accident … and his death has been registered under number 15202 in Deceased Registry 1360 [1981], district 19 of the birth registry for Tehran.

This copy of the extract from the death certificate is presented to Mr. Sirous, son of Rushan, intact and untarnished, [in response to] a written request

Signature of the Representative and the seal of District 19

[Signature over official stamp]