TNAG-2319-FCO40-3363-Petitions-from-members-of-the-public-regarding-Hong-Kong-1991 — Page 141

APPENDIX B

t.

R.G. 721(S.)

6670018

200x100-6/71-B85167

REGISTRAR GENERAL'S DEPARTMENT

HONG KONG

香港註册總署

43./.3.3...

Entry No. 4

註冊號碼

BIRTHS AND DEATHS REGISTRATION ORDINANCE, SECTION 17(2)

生死註冊條例第十七欵第二段

FORM 12

十二號表格

CERTIFICATE OF REGISTRATION OF DEATH 死亡註冊證書

Name of deceased person

死者姓名

Lan... Mick you.

yil.....

M

Sex

性别

Age

Z.Z...

年齡

Date of death

4823

死亡日期

Date registered

註冊日期

5973

Address at death. No. 9 Wang Sed 8.4.

死亡地址

Signature of registrar

註册官簽名

(a

This certificate must be produced on demand by a police officer to prove that the name of the person entered has been registered.

此證書如遇警索閱須交出察看以証明上開之人名經已註冊

NO FEE IS PAYABLE FOR THIS CERTIFICATE 領此證書無須繳費

་