APPLICATION FOR DEATH CERTIFICATE - South Africa

1 5. Place of 017-0064BI 132 republic OF South AFRICADEPARTMENT OF home AFFAIRSAPPLICATION FOR DEATH CERTIFICATEThis form must be handed in at a Regional or District office of the department of home affairs together with the prescribed REASON WHY THE CERTIFICATE IS REQUIRED MUST BE SUBMITTED [In terms of section 29 of theBirths and Deaths Registration Act, 1992 (Act No. 51 of 1992)]..For use in the republic of South Africa a computer printed CERTIFICATE of DEATH particulars is normally issued. Such a CERTIFICATE complies with the requirements for which a DEATH CERTIFICATE is required. An unabridged CERTIFICATE is available and is issued mainly for overseas use. Indicate with an X which document is certificateComputer printed certificateCertified copy of registerA. PARTICULARS OF DECEASED1. Identity Number3. Surname4. Maiden name if married woman6.

2 Forenames in full7. Date of death9. Town/City of death11. Name of undertaker1. Surname2. Initials3. Identity number4. Residential address5. Postal addressTelephone number (Work)Telephone number ( home )B. PARTICULARS OF APPLICANT8. DEATH entry number(Must be completed by regional or district office)2. Date of birthYM D10. Province6. Postal address codeTelephone codeTelephone D