80   No. 41970 GOVERNMENT GAZETTE, 12 OCTOBER 2018 G.P.-S. 09/18 DHA-154/132/130 REPUBLIC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS APPLICATION FOR COPY OF A CERTIFICATE A0000000001 Annexure 16 To be completed in full and submitted at the Department of Home Affairs’ office or to a South African embassy or consulate. The form to be completed in BLACK INK with BLOCK LETTERS. Please mark with þ the CORRECT box, where required. Applications that are not legible shall not be accepted. Please select below which certificate is required: Birth Certificate Certified copy of Birth Register (vault copy) Death Certificate Confirmation of Birth Certified copy of marriage register Marriage certificate Certified copy of Death Register (vault copy) Handwritten death certificate Specify type of marriage Please provide reasons for applying for this certificate: A. PARTICULARS OF PERSON WHOSE CERTIFICATE IS REQUIRED Identity number/Passport No. Birth entry number Refugee/Asylum Seeker Permit PR Permit No. Date of Birth Y Y Y Y M M M M M M M M M D D Citizenship Surname Previous/Maiden surname Forenames in full Place of birth: City/Town District/Province of Birth Country of Birth Identity No/Passport No. of Spouse Date of Marriage/Death Death entry number Y Y Y Y M M M M M M M M M D D Citizenship Place of Marriage/Death Birth, Death, Marriage Entry No. Place of Burial: City/Town District/Province of Death Country of Death B. PARTICULARS OF APPLICANT Identity number/Passport No. Citizenship Refugee/Asylum Seeker Permit PR Permit No. Surname Forenames in full Residential address: Street Town/Village District/Province Postal code Telephone no., incl. area code Cell phone no. E-mail address Postal address Province Relationship concerned: to the person Postal code Mother/Parent A Father/Parent B Legal guardian (Attach proof of guardianship) Husband/Wife Social Worker or Authorised Officer, provide case number: Legal representative (Attach Power of Attorney) Next of kin: Specify I .................................................................................................................................. (the applicant), hereby declare under oath that the information submitted is to the best of my knowledge and belief true and correct and that in case it is not true I shall be guilty of an offence and on conviction liable to a fine or imprisonment or both such fine and such imprisonment. Signature of Applicant: Date: Page 1 of 2 Y Y Y Y M M This gazette is also available free online at www.gpwonline.co.za M M M M M M M D D