No. 41970   75 STAATSKOERANT, 12 OKTOBER 2018 No.QQ94295 G .°.-5. (83/BI -18) 33;B REPUBLIC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS UNABRIDGED DEATH CERTIFICATE (Issued in terms of Act 51 of 1992) Certified a true extract from the death register of: 1. Identity Number 2. Surname 3. Forenames in full 4. Date of birth: 6. Occupation 8. Country of birth Year Month Day 5. Gender 7. Marital status 9. Nature of pension 10. Residential address PARTICULARS OF DEATH 11. Date of death: Year Month J Day r 1-- 12. Place of death 13. Cause of death 14. Duration of disease or last illness 15. Name of medical practitioner 16. Intended place of burial INFORMANT 17. Capacity 18. Signed by (Official date stamp) Director- General Home Affairs This gazette is also available free online at www.gpwonline.co.za