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CERT~'~D COPY ~ OF AN ENTRY
Parsaant to the Births and Deaths Registration Act 1953
DEATH ~ ~ Nom' s~
Regi~atration district ~~5~ D d Administrative area
Sub-diatria ~Stat. II~.L Sd1e~ ~ KeMte:.9/a. a.,L G~att~SlaL
1. Date and play of loth ~f E'C~/t~i ~a~t,8t,ts~r X77
~d C~i~- ara ana~/~ j~. ~ ~ j ~ao/v.~i~ , C ~slSta.
2. Name and surname 3. Sex
- 'lr?e~CA._
J v,M ~~w i ~ S'/~C DIQ SK l 4. Maidea swnaate
of woman who
has married
S. Date and place of birth ik~ ~L~K [40
6. ooa,parion and usual address
P~ et~,r.a~sr ~ '
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7. (a) Name and surname of informant (b) Qualification
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(c) Usual address
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` 8. cause of death
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9. I certify that the particulars given by me above are true to the best of my koowkdge and belief
.f Stlre~tS~ei Si~~aattuurree .
€ _ - - . _ ~ • _ . _ - _ _ _ . of informant
10. Date of regyyis~~tr~~ation ~ 1 I. Signature of registrar Q
J~~ ~Jl.` Ig77 Q. Pq 7'Ts ~vtvi? a`~r'~°'~
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1980 ~i~l' 16 P#~ 2~ 43
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TRASA.
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Certifi to be a trttg copy of an entry in a register in my custody
- ---------------------.------~_.---,-.----.-.---.----.........-...Superintendent Registrar._._.s37_G...N_
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