Translation Of Death Certificate
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1TRANSLATION
OF DEATH CERTIFICATE
OF:
1. Full Name
First Middle
LAST
2. Date of Death:
Month Day
Year
CityNillagerrown
Region (if applicable)
Country (name of country at time ofbirth)
First Middle
Current Last
Current
Name:
Sa. Surviving
Birth Last Name
Sb. Date of Birth:
(MonthlDaylYear)
Name
(Maiden Name)
if
Applicable
6. Filing
City Region (if applicable)
Country (name of country at time ofbirth)
7. Name of
Full Name
18.
Daytime Phone:
I
(include area code)
o
Professional translator
o
Community Assistance Center Staff/Volunteer
o
Teacher
o
Government employee 0 Other (specifY):
LA TOR CERTIFICATION
STATEMENTS:
I
affirm that
I
have the language skills
required to accurately translate information into English from the language used to complete the
original death certificate.
I
affirm that
I
am neither related to, nor do
I
have any financial or personal connection to, the
person who is the subject of the death certificate referenced in this translation (other than a
standard professional translation fee that
I
may charge for providing translation services).
I
further affirm, to the best of my knowledge and belief, that the attached death certificate
presented to me for translation contains the above stated facts, translated into English
/'
Translator's
Signature
Date Sil?:ned
CERTIFICATE
OF NOTARY PUBLIC
PLACE FOR NOTARY SEAL
(MANDATORY)
Subscribed and sworn before me this
day of
"
_
Month
Year
Notary of
county,
state of
_
My Commission expires
_
(MDnthlDaylYear)
Printed Name of Notary
_
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