Translation of death certificate

Ukraine

Re-issue

DEATH CERTIFICATE

Family name —

Name —

Patronymic name —

died on —- (—)

at the age of —

that is registered in the civilian registry book record No.— from —

Place of death town of —-, Ukraine

Place of registration registry office of —- regional administration of justice of —- oblast

Data of issue: —

Signature of the head of the

registry office: signature /—/

Round official seal

registry office of —- regional administration of justice of — oblast.