No. 41970   73 STAATSKOERANT, 12 OKTOBER 2018 DHA-1577 REPUBLIC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS home affairs NiitalSO Serial Number Annexure 8 Department: PROOF OF NOTICE OF DEATH Home Affairs REPUBLIC OF SOUTH[Births AFRICA and Deaths Registration Act 51 of 1992] To be completed in BLACK INK with BLOCK LETTERS. Please mark with R the CORRECT box, where required. Date of Issue Y Y Y Y M M D D A. PARTICULARS OF DECEASED Identity number Passport number (if foreigner) Date of birth Y Y Y Y M M D D Date of death Y Y Y Y M M D D M M D D M M D D Citizenship Sex Surname Previous or Maiden surname Forenames Place of death: City/Town Province Street Residential address Town / Village Code Province B. PARTICULARS OF INFORMANT Identity number Date of birth Y Passport number (if foreigner) Y Y Y Sex Citizenship Surname Previous or Maiden surname Forenames Residential address Street Town / Village Code Province Telephone no., incl. area code Cell phone no. E-mail address C. FOR OFFICIAL USE ONLY It is hereby certified that the death of the person whose particulars appear in Part A has been reported. Surname DHA Office stamp Forenames Persal No. Signature Date signed Y Y NB. This document is a not a death certificate. At the registration of the death, a death certificate will be issued to the informant. This gazette is also available free online at www.gpwonline.co.za Y Y