‫اشهاد‬

‫نحن الموقعون اسفله‬

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‫‪...............................................................................................................................................‬‬ ‫‪)2‬‬
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‫‪.....................................................................................................................................................‬‬ ‫‪)3‬‬
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‫نصرح ونشهد بأننا نعرف معرفة تامة‬

‫المرحوم (ة ) ‪...............................................................................................................................:‬‬

‫المولود (ة ) بتاريخ ‪.......................................................................................................................:‬‬

‫من ولديه (ها ) ‪...........................................................................................................................:‬‬

‫الساكن (ة ) ب ‪...........................................................................................................................:‬‬

‫قد توفي بدوار ‪......................................................:‬فرقة ‪...............................................................:‬‬

‫قبيلة ‪...............................................................:‬بتاريخ ‪............................................................:‬‬

‫اشهادا تاما وكامال والسالم‬

‫امضاء الشهود‬

‫‪.........................................)3..........................................)2.........................................)1‬‬