Translation of death certificate

Ukraine

State Emblem

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.