[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 Organisation for Civil Registration

Copy of Death Certificate

 

Number: 276826

Series: 3/1

 

On the date of 10 Esfand 1360 [1 March 1982], house/ establishment number: ----- on lane: ----- street: ----- city: ----- borough:----- village: ----- region: ----- district: -----  Mr. Seyyed Hosein, Family Name: Vahdat-Hagh, son of Seyyed Mohammad and Fatemeh, date of birth: 1304 [1926],  holding birth certificate number: [redacted], issued by city-----borough-----village-----region-----within jurisdiction of the Department of Civil  Registration of Shiraz, as a result of ----- sickness/accident-----  had died and his death was registered in the list of the deceased in the year 1361 [1983] of district [illegible] within the jurisdiction of the Department of Civil Registration Office of Tehran under registration number 161.

This death certificate, without any defect, scratch or crossing out, was delivered to Mr./Mrs.----- son of ----- according to a written petition.

Place of signature and stamp of the representative of the Department of Civil Registration Office of the city of -----

 

[Signature on official stamp]

23 Khordad [?] [13 June [?]]

 

[Handwritten note on top of the page] 10 Esfand 1362 [29 February 1984]

N-82-100000 D 100 B 4/67