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SOCIALIST REPUBLIC OF VIETNAM Independence - Freedom - Happiness The People’s Committee Commune: Lien Bat District: Ung Hoa Province: Ha Tay Model: TP/HT-1999-C.2 No: 01 Book: 01 - Death Certificate (Re-registration) Full name: Bui Dam Quang Date of birth: May 3rd, 1942 Ethnic group: Kinh Native place (1): Bat Chua – Lien Bat – Ung Hoa – Ha Tay Sex: Male Nationality: Vietnamese Residence address/Last temporary address (2): Lien Bat – Ung Hoa – Ha Tay ID No./ alternative documents (3): No.: Issued in…………………………on……………………………… Died at ……………on February, 25th, 2001 Place of death: Bat Chua – Lien Bat – Ung Hoa – Ha Tay Cause of death: Suddenly catching cold Officer in charge of Birth, Marriage, Death (Name, position, signature) Lien Bat, May, 15th, 2006 On Behalf of the People’s Committee Vice-Chairman (Signed and sealed) Certified as original copy Date: May 30th, 2006 Number: 382 Book: 05 CN-BS Notary NGUYEN THI MINH TAM
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