FEDERAL REPUBLIC OF NIGERIA

SAGBAMA LOCAL GOVERNMENT COUNCIL

SHOMOLUE, RIVER STATE-NIGERIA
Birth/ Death Registry
DEATH CERTIFICATE

Issued under the Births and Deaths Etc. (Compulsory Registration) Decree 69 of 1992

Registration Centre ______________________ Certificate Number D NO 963876

Town / Village__________________________

L.G.A _________________________________

State_________________________________

This is to certify that the death, details of which are recorded herein has been registered on

1 Full Name

2 Sex: ____________

3 Date of Death

4 Age at Death ___________

5 Place of Death __________

6 Full Address of Usual Place of Residence of Deceased __________________________________________

_____________________________________________________________________________________

Place of Issue __________________________ Name of Registrar ____________________

Date: ________________________ Signature of Registrar: _________________