76   No. 41970 GOVERNMENT GAZETTE, 12 OCTOBER 2018 G.P.-S. 09/09 DHA-6 DEPARTMENT OF HOME AFFAIRS REPUBLIC OF SOUTH AFRICA DECLARATION RELATING TO A STILL BIRTH BY A PERSON OTHER THAN A MEDICAL PRACTITIONER Quote DHA 1663 Serial Number [Births and Deaths Registration Act 51 of 1992] [Section 9] 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 the CORRECT box with 5, where required. Applications that are incomplete or not legible shall not be accepted. A. PARTICULARS OF THE STILL BORN CHILD Surname of Child Forenames (if any) Y Date of still birth Y Y Y M M M M M M M M M Place of birth: City/Town D Gender (write month in full) Province PARTICULARS OF DECLARANT Left thumbprint of Declarant B. D Identity number Surname Forenames Residential address: Street Town/Village Province Telephone no., incl. area code The Deceased is my: Cell phone no. Parent Spouse Child Postal code Other, Specify DHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHADHAHADDHADHA I hereby declare under oath that the information submitted in this form is true and correct, and I understand that a false statement is punishable under section 31 of the Birth and Death Registration Act 51 of 1992 Signature C. Date Y Y Y Y M M D D DECLARATION (For offices use only) I certify that before administering the prescribed oath/solemn declaration I put the following questions to the deponent and noted his/her replies in his/her presence: Office Stamp Do you know and understand the contents of the above declaration? Answer: Have you any objection to taking the prescribed oath? Answer: Do you regard the prescribed oath/solemn declaration to be binding on your conscience? Answer: I certify that the deponent has acknowledged that he/she knows and understands the contents of the above declaration which was sworn to/ affirmed before me and that the deponent's signature/thumb-print/mark was placed in my presence. I understand that if I gave any false statement, I shall be guilty of an offence and on conviction liable to a fine or to imprisonment for a period not exceeding five years or to both such fine and such imprisonment (Section 31(1)(b) of the Act 51 of 1992.) Signature of the Commissioner of Oaths Identity number Date Y Y Y Y Persal Number Surname Forenames Street Address Designation (Rank) This gazette is also available free online at www.gpwonline.co.za M M D D