CILACAP DISTRICT GOVERNMENT

SUBDISTRICT BANTARSARI

BANTARSARI VILLAGE

BANTARSARI STREET NUMBER 2, CILACAP 54258

The undersigned is the village head of Bantarsari, explain truly that:

Name : Muhamed Ghouse S/O A Ismael Sahed

Place & Birth : India, 22-09-1959

Nationality : Singapore

Religion : Islam

Work : Entrepreneur

Address : Petenangan village 02/03 Bantarsari Village, Subdistrict Bantarsari

That the person actually died at home due to hepatitis on Saturday 12th September 2015
and was buried on Saturday 12th September 2015 at public cemetery district Gandrungmanis
village, subdistrict Gandrungmangu, district Cilacap.

Thus a statement is made in good faith to make check

Head Village of Bantarsari

Ngato Urohman