68   No. 41970 GOVERNMENT GAZETTE, 12 OCTOBER 2018 G.P.-S. 09/09 REPUBLIC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS NOTICE OF DEATH / STILL BIRTH G.P.-S. 09/09 DHA-1663 A Page 3 of 3 [Births and Deaths Registration Act 51 of 1992] C [Regulations 11 and 14] GOV543/83 11/13 OG REPUBLIC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS G.P.-S. 09/09 NOTICEOF OFDEATH DEATH//STILL STILLBIRTH NOTICE BIRTH G.P.-S. 09/09 [Births and Deaths Registration Act 51 of 1992] REPUBLIC OF SOUTH AFRICA [Regulations 11 and 14] DEPARTMENT OF HOME AFFAIRS REPUBLIC OF SOUTH AFRICA Instructions: Section E to be completed by Funeral Undertaker. The undertaker must take his or her finger print, the finger print of the deceased and the informant. Authorised Funeral DEPARTMENT OF AFFAIRS To be completed in full and the Department ofNOTICE Home office by theHOME informant authorised funeral undertaker. Undertaker or Informant maysubmitted submit theat completed form to the nearestAffairs Home Affairs office. OF DEATH / STILLorBIRTH E. PARTICULARS OF FUNERAL UNDERTAKER The form to be completed in BLACK INK with BLOCK LETTERS. Please mark with 3 the CORRECT box, where required. 47. Name of Funeral Parlour NOTICE DEATH / STILL BIRTH [Births andOF Deaths Registration Act 51may of 1992] All fields are COMPULSORY. Incomplete applications and applications that are not legible be considered invalid. (Note: The fingerprints be taken by the undertaker) [Regulations 11 and 14] 48. DHA Designation No. of the deceased, the informant and the undertaker must 49. Company Reg. No. [Births and Deaths Registration Act 51 of 1992] [Regulations 11 and 14] 47. Name Funeral Parlour 51. Identity No. (Passport No. if foreigner) 51 Id tit ofN (P tN f i ) 52. Surname 48. Designation No.OF E. DHA PARTICULARS FUNERAL UNDERTAKER 49. Company Reg. No. Instructions: Section E OF to be completed by Funeral Undertaker. The undertaker must take his or her finger print, the finger print of the deceased and the informant. Authorised Funeral E. Forenames PARTICULARS FUNERAL UNDERTAKER 53. 50. SARS Reg. No. (Income tax reference no.) Undertaker or Informant may submit the completed form to the nearest Home Affairs office. Instructions: Section E to be completed by Funeral Undertaker. The undertaker must take his or her finger print, the finger print of the deceased and the informant. Authorised Funeral Details of Funeral UndertakerStreet or Authorised Representative 54. Business Address 47. Name of Funeral Parlour Undertaker or Informant may submit the completed form to the nearest Home Affairs office. 51. Identity No. (Passport No. if foreigner) 51 Id (P fTown i ) 47. Name ofN Funeral Parlour 48. DHAtitDesignation No.t N 49. Company Reg. No. 52. Surname Province 48. DHA Designation No. 50. SARS Reg. No. (Income tax reference no.) 53. Forenames Telephone No. (Office) Details of Reg. Funeral or Authorised 50. SARS No. Undertaker (Income tax reference no.) Representative Postal Code 49. Company Reg. No. Cellphone No. 54. Business Address Street Details of Undertaker Representative 51. Identity No. (P (Passport No. if foreigner) 51 Id tit Funeral N tN f or Authorised i ) 56. Date of Cremation (if applicable) 57. Burial (City / tTown Village) 51. Identity No. (Passport No. if/foreigner) 51 Place Id tit ofN (P N fTown i ) 52. Surname Province Province 52. Surname 53. Forenames 59. GravePostal No. (ifCode available) Telephone No. (Office) Name of person who collected the deceased: 53. 54. Forenames Business Address Street 56. Date of Cremation (if applicable) 57. Place of Burial (City / Town / Town Village) 61. Surname Province 58. Date of Burial 62. Forenames Telephone No. (Office) Name of person who collected the deceased: Telephone No. (Office) Place signed 60. Identity (Passport No. if /foreigner) DatePlace signed 57. ofNo. Burial (City / Town Village) Y Y Y M M D D Y Y Y M Y M D D 61. Surname 57. Burial (City /USE TownONLY / Village) F. Place FORofOFFICIAL Signature 56. Date of Cremation (if applicable) 59. Grave No. (if available) 62. Forenames Name of person who collected deceased: Registration of death approved,the DHA-1663 received by (particulars of DHA official): Y Y M M D D Province 59. GravePostal No. (ifCode available) Cellphone No. Cellphone No. 56. Date of Cremation (if applicable) DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA Y Y Postal Code Y Province Office stamp of funeral undertaker Cellphone No. 55. Date of No. collection of corpse 60. (Passport No. if Street foreigner) 54. Identity Business Address Town 59. Grave No. (if available) ertaker ertaker ertaker of funeral unde ertaker Left thumbprint Left thumbprint of funeral of Left funeral unde thumbprint unde of funeral Leftunde thumbprint E. PARTICULARS OF FUNERAL UNDERTAKER 50. SARS Reg. No. (Income tax reference no.) Instructions: Section E to be completed by Funeral Undertaker. The undertaker must take his or her finger print, the finger print of the deceased and the informant. Authorised Funeral Details of Funeral Undertaker or Authorised Representative Undertaker or Informant may submit the completed form to the nearest Home Affairs office. Office stamp of funeral undertaker Province Province of DHA OfficeOffice stampstamp of funeral undertaker Office stamp of funeral undertaker Name of person who collected the deceased: 63. Identity 60. No. (Passport No. if foreigner) Place signed DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA 60. No. (Passport No. if foreigner) 61. Surname 64. Identity 61. F. Surname FOR OFFICIAL 62. Forenames 65. Signature USE ONLY 62. Forenames Registration 66. Persal No.of death approved, DHA-1663 received by (particulars of DHA official): Place signed 63. Identity No. Documents included with this notice: deceased's ID Date signed Place signed Y Y Y Y M M D Copy D of theSignature DHA - 6 (if applicable) 64. Surname F. FOR OFFICIAL USE ONLY Signature DHA-1663 was submitted by: Informant F. Forenames FOR OFFICIAL USE ONLY 65. Registration of death approved, DHA-1663 received by (particulars of DHA official): Office stamp of DHA DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA Copy of ID document of the informant DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA DHA - 1680 (if applicable) Funeral Undertaker Office stamp of DHA Office stamp of DHA 66. Persal 63. IdentityNo. No. Registration of death approved, DHA-1663 received by (particulars of DHA official): Documents included with this notice: 63. Identity No. 64. Surname Copy of the deceased's ID Copy of ID document of the informant 64. 65. Surname Forenames DHA-1663 was submitted by: 65. Forenames 66. Persal No. DHA - 6 (if applicable) DHA - 1680 (if applicable) Informant Funeral Undertaker Documents 66. Persal No.included with this notice: Copy of the deceased's ID Copy of ID document of the informant Documents included with this notice: DHA -of 6 the (if applicable) Copy deceased's ID DHA 1680 (if applicable) Copy-of ID document of the informant DHA-1663 was submitted by: Informant DHA - 6 (if applicable) Funeral Undertaker DHA - 1680 (if applicable) DHA-1663 was submitted by: Informant Funeral Undertaker GOV543-83T Notice of Death-Stillborn DHA1663 154183.indd 3 This gazette is also available free online at www.gpwonline.co.za 2013/11/14 06:41:39 AM