DEATH CERTIFICATE WORLD BY FAUZAN PONSEL

DISTRICT URCHIN

  KECAMATAN JELIMPO

VILLAGE CENTER PELUNTAN

Address: Hamlet Peluntan Hall, Village Hall Peluntan, Kec.Jelimpo, 79 357

DEATH CERTIFICATE WORLD
Number: 474.1 / 01 / BLP / 2013

Head of Village Center District Peluntan Jelimpo, Porcupine District hereby stated that the name of this dibahwah:

Name: UNYENG
Date and Place of Birth: Kebadu, January 15, 1976
Gender: Male
Marital Status: Married Already
Religion: Catholic
Occupation: Farmer
Nik: 6I08010610500004
No.. BA: 107 083
Address: RT: 06/02
Hamlet: Dara ITAM III
Village: Hall Peluntan
Sub-district: Jelimpo
District: Hedgehogs

FACTS

a. That the name of the above are true Population III RT.06/RW.02 Hamlet Dara Itam Village Hall Peluntan Kecamatan Jelimpo Porcupine District.
b. It is true that the above named deceased Ranto Lanu Hamlet, Village Hall Peluntan, Kec.Jelimpo, Kab.Landak on:
Day: Sunday
Date: January 20, 2013
Time: 12.00 pm (12 Noon)
Cause of Death: Structural Disease (Chronic)

Thus this letter is made to be used properly.

 IN FOR IN: CENTER PELUNTAN

TO DATE: 22 JANUARY 2013

VILLAGE CENTER HEAD PELUNTAN

DISTRICT JELIMPO

Suandi