No. 41970   77 STAATSKOERANT, 12 OKTOBER 2018 DHA-14B REPUBLIC OF SOUTH AFRICA DEPARTMENT OF HOME AFFAIRS Barcode Annexure 12 REMOVAL ORDER [Births and Deaths Registration Act 51 of 1992] The form 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 Bar-code number of DHA-1663 Serial number of DHA-1663 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 Citizenship Sex Surname Previous or Maiden surname Forenames B. AUTHORITY FOR REMOVAL OF CORPSE This certificate grants the authority for the removal of the corpse from magisterial district in which the death occurred to a place outside the particular magisterial district. Order issued by: (tick applicable) SAPS Force No. Forensic Pathologist HPCSA No. Surname Forenames Telephone No. Date Signed Office Stamp Y Y Y Y M M D D Signature C. RECIPIENT OF AUTHORITY OF REMOVAL (if Funeral Undertaker please provide details of the business) Identity number (passport if foreigner) Surname Maiden name Forename Name of Funeral Palour DHA Designation number Business address: street Street Telephone number Town Province Postal code Telephone no., incl. area code Cell phone no. E-mail address Relation to the deceased: Signature of recipient Parent Spouse Funeral undertaker Other Specify: Date received Y Y This gazette is also available free online at www.gpwonline.co.za Y Y M M D D