[PROVISIONAL TRANSLATION FROM PERSIAN]

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

Date: 28/1/1363 [17 April 1984]

Number: 33720

(G Series)

[Emblem]

Islamic Republic of Iran

Tehran Municipal Council

Behesht e Zahra

The sum for burial recorded in the table below was received from Mr. Rahimian and was deposited in account number 91002 of the Cemeteries Organisation of Tehran, Behesht e Zahra Bank Melli

[illegible]

Sum received: 9000

Account number [illegible]

Date: 28/1[17 April]

Bank Melli Iran

Behesht e Zahra Kiosk

Warning: Receipts with an incomplete table by [illegible] are not valid

[handwritten note, signature and stamp at the top of the page]

[handwritten note, number and date at the bottom of the page]

Execution number [without any identity details]

Registry of Birth

1766

18/1/1363