05.06.2003 yildagi 249-son
Hujjat kuchini yo‘qotgan 01.07.2012
 LexUZ sharhi
1-banddagi “qayd etilganligi” so‘zlari “tuzilganligi” so‘zi bilan almashtirilsin;
3-band o‘z kuchini yo‘qotgan deb hisoblansin.

O‘zbekiston Respublikasi
GERBI


NIKOHDAN AJRALGANLIK HAQIDA GUVOHNOMA

Fuqaro _________________________________________________________________________

(familiyasi)

________________________________________________________________________________

(ismi, otasining ismi)

va fuqaro _______________________________________________________________________

(familiyaci)

________________________________________________________________________________

(ismi, otasining ismi)

nikohdan ajralishdi, bu haqda ____ yil____ oyining____ kunida___ -son bilan dalolatnoma yozuvi
qayd etildi. Nikohdan ajralgandan keyin quyidagi familiyalar berildi:

erga ___________________________________________________________________________

xotinga _________________________________________________________________________

Qayd etish joyi __________________________________________________________________

(FHDYo organining nomi)

Guvohnoma fuqaro ________________________________________________________________

(familiyasi)

_______________________________________________________________________ ga berildi.

(ismi, otasining ismi)

Berilgan vaqti ____________ yil “ ______ ” __________________________________________

Fuqarolik holati dalolatnomalarini
yozish organi mudiri ______________________

Muhr

I—O'z № 0000000

(1-ilovaning davomi)


SVIDETELSTVO O RASTORJENII BRAKA

Grajdanin ______________________________________________________________________

(familiya)

________________________________________________________________________________

(imya, otchestvo)

i grajdanka _____________________________________________________________________

(familiya)

________________________________________________________________________________

(imya, otchestvo)

rastorgli brak, o chem _________________ chisla ____________ mesyatsa ________________ goda

Proizvedena aktovaya zapis za № ___________________.
Posle rastorjeniye braka prisvoyeni familii:

muju ___________________________________________________________________________

jene ___________________________________________________________________________

Mesto registratsii _______________________________________________________________

(naimenovaniye organa ZAGsa)

________________________________________________________________________________

Sviditelstvo vidano grajdaninu (ke) ______________________________________________

(familiya)

_________________________________________________________________________________

(imya, otchestvo)

Data vidachi “ _______ ” ________________________________________________________ goda

Zaveduyuщiy(aya) organom zapisi
aktov grajdanskogo sostoyaniya _______________________
Pechat

I—O'z № 0000000

(1-ilovaning davomi)

DIVORCE CERTIFICATE

The marriage of _____________________________________________________________________

(surname)

__________________________________________________________________________________

(given names)

and ______________________________________________________________________________

(surname)

_________________________________________________________________________________

(given names)

is dissolved, record of divorce No. ___ was failed on ________ of the year _______________________.
Upon dissolution of marriage the following surnames were given to husband ______________________
wife _____________________________________________________________________________
Place of registration _________________________________________________________________

(name and location of the Registry office)

________________________________________________________________________________
The present Certificate is issued to ______________________________________________________

(surname)

________________________________________________________________________________

(given names)

Date of issue ______________________________________________________________________

(day, month, year)

Registrar _______________
Seal

I—O'z № 0000000

O‘zbekiston Respublikasi
GERBI

NIKOHDAN AJRALGANLIK HAQIDA GUVOHNOMA
NEKEDEN AJЫRASQANLЫFЫ HAQQЫNDA GYO‘ALЫQ


Fuqaro______________________________________________________________________

Puxara

(familiyasi,/ familiyasi)

____________________________________________________________________________

(ismi, otasining ismi /ati, ekesinin ati)

va fuqaro ___________________________________________________________________

hem puxara

(familiyasi / familiyasi)

____________________________________________________________________________

(ismi, otasining ismi /ati, ekesinin ati)

nikohdan ajralishdi, bu haqda _______ yil__________ oyining________ kunida ________ - son bilan dalolatnoma yozuvi qayd etildi.
nekeden ajirasti, bul haqqinda______jil _________ayinin ________ kuni __________ - san menen akt jazio‘i dizimge alindi.
Nikohdan ajralgandan keyin quyidagi familiyalar berildi:
Nekeden ajirasqannan keyin tomendegi familiyalar berildi:

erga_________________________________________________________________________
erge

xotinga ______________________________________________________________________
hayalga

Qayd etish joyi_______________________________________________________________
Dizimge aling‘an jeri

(FHDYo organining nomi/PXAJ organiniң ati)

Guvohnoma fuqaro ____________________________________________________________
Gүo‘aliq puxara

(familiyasi,/ familiyasi)

__________________________________________________________________ ga berildi.
ge berildi

(ismi, otasining ismi /ati, ekesinin ati)

Berilgan vaqti __________ yil “ _______ ” ____________________
Berilgen o‘aqti __________ jil “ _______ ” ___________________
Fuqarolik holati dalolatnomalarini yozish organi mudiri ______________________
Puxaraliq halati aktlerin jazio‘ organi baslig‘i _____________________________

Muhr
Mor

I—QQ № 0000000





(2-ilovaning davomi)

SVIDETELSTVO O RASTORJENII BRAKA

Grajdanin ___________________________________________________________________

(familiya)

____________________________________________________________________________

(imya, otchestvo)

i grajdanka__________________________________________________________________

(familiya)

____________________________________________________________________________

(imya, otchestvo)

rastorgli brak, o chem __________ chisla _________ mesyatsa _____________ goda

Proizvedena aktovaya zapis za № ____________.

Posle rastorjeniye braka prisvoyeni familii:

muju_______________________________________________________________________

jene________________________________________________________________________

Mesto registratsii____________________________________________________________

(naimenovaniye organa ZAGsa)

____________________________________________________________________________

Sviditelstvo vidano grajdaninu (ke) ____________________________________________

(familiya)

____________________________________________________________________________
(imya, otchestvo)

Data vidachi “ _____ ” ___________________ goda



Zaveduyuщiy(aya) organom zapisi
aktov grajdanskogo sostoyaniya ___________________



Pechat



I—O'z № 0000000






(2-ilovaning davomi)

DIVORCE CERTIFICATE

The marriage of ________________________________________________________________

(surname)

____________________________________________________________________________

(given names)

and _________________________________________________________________________

(surname)

____________________________________________________________________________

(given names)

is dissolved, record of divorce No. ____ was failed on ______ of the year _________.

Upon dissolution of marriage the following surnames were given to
husband _____________________________________________________________________

wife _________________________________________________________________________

Place of registration _____________________________________________________________

(name and location of the Registry office)

_____________________________________________________________________________

The present Certificate is issued to__________________________________________________

(surname)

____________________________________________________________________________

(given names)

Date of issue__________________________________________________________________

(day, month, year)



Registrar ______________



Seal



I—O'z № 0000000

O‘zbekiston Respublikasi
GERBI

TUG‘ILGANLIK HAQIDA GUVOHNOMA

Fuqaro______________________________

Otasi ______________________________

(familiyasi)

(familiyasi)

____________________________________

____________________________________

(ismi, otasining ismi)

(ismi, otasining ismi)

______yil________ oyining_____ kunida

millati _____________________________

____________________________________

Onasi ______________________________

(familiyasi)

______________________________tug‘ildi

____________________________________

(raqam va so‘z bilan)

(ismi, otasining ismi)

Tug‘ilgan joyi: ____________Respublikasi

millati _____________________________

______________________________viloyati

Qayd etish joyi_______________________

(FHDYo organining nomi)

______________________________tumani

____________________________________

_______________shahri, shaharchasi, qishlog‘i

Berilgan vaqti____yil “___” ____________

Bu haqda ___yil ______oyining____ kunida

__- son bilan dalolatnoma yozuvi qayd etildi.

Fuqarolik holati dalolatnomalarini
yozish organi mudiri _________________

Muhr



I—O'z № 0000000


(1-ilovaning davomi)

SVIDETELSTVO O ROJDENII

Grajdanin (ka) ______________________

Otets_______________________________

(familiya)

(familiya)

____________________________________

____________________________________

(imya, otchestvo)

(imya, otchestvo)

rodilsya (las) “____” _____________ goda

Mat_______________________________

(familiya)

____________________________________

____________________________________

(imya, otchestvo)

____________________________________

natsionalnost _____________________

(tsiframi i propisyu)

Mesto rojdeniya: Respublika ___________

Mesto registratsii ___________________

(naimenovaniye organa ZAGSa)

_____________________________ oblast

____________________________________

______________________________rayon

Data vidachi “ ____ ” _____________ goda

gorod, posyolok, kishlak _______________

Ob etom “ ______ ” _______________ goda

Zaveduщiy (aya) organom zapisi
aktov grajdanskogo sostoyaniya ______

proizvedena aktovaya zapis za № _______

Pechat


I—O'z № 0000000

(1-ilovaning davomi)


BIRTH CERTIFICATE

Citizen ______________________________

Father _______________________________

(surname)

(surname)

____________________________________

____________________________________

(given names)

(given names)

was born on __________________________

nationality (etnic) _______________________

(day, month, year in figures and words)

____________________________________

Mother ______________________________

(surname)

____________________________________

____________________________________

(given names)

Place of birth: Republic __________________

nationality (etnic) ______________________

_______________________________region

Place of registration _____________________

(name and location of the Registry Office)

______________________________district

____________________________________

___________________________city, village.

Date of issue “ ___ ” ___________________

Birth record No. ____ was filed on _________

Registrar _______________________

(day, month, year)

Seal



I—O'z № 0000000

O‘zbekiston Respublikasi
GERBI

TUG‘ILGANLIK HAQIDA GUVOHNOMA
TUO‘ЫLG‘ANLЫG‘Ы HAQQЫNDA GҮO‘ALЫQ

Fuqaro __________________________________

Otasi __________________________________

Puxara (familiyasi/familiyasi) Ekesi (familiyasi/familiyasi)

____________________________________________

_______________________________________

(ismi, otasining ismi/ati, Ekesiniң ati)

(ismi, otasining ismi/ati, Ekesiniң ati)

_________yil __________ oyining ________ kunida
_________jil __________ ayinin________ kuni

millati _______________________________
milleti

____________________________________

Onasi _________________________________
Anasi

(familiyasi/familiyasi)

____________________________________ tug‘ildi

_______________________________________

(raqam va so‘z bilan/san hem soz benen) tug‘ildi

(ismi, otasining ismi/ati, Ekesiniң ati)

Tug‘ilgan joyi: ___________________Respublikasi
Tuo‘ilg‘an jeri:___________________Respublikasi

millati ________________________________
mileti

____________________viloyati

Qayd etish joyi __________________________

oblasti

Dizimge aling‘an jeri (FHDYo organining nomi)

________________________________________

(FHDYo organining nomi/PXAJ organiniң ati)

____________tumani
rayoni

_________________________________________

____________ shahri, shaharchasi, qishlog‘i
____________ qalasi, posyolkasi, ao‘ili.

Berilgan vaqti____yil “____” _______________
Berilgen o‘aqti ___jil “____” _______________

Bu haqda ___yil ______oyining__ kunida
Bul haqqinda___jil __ayiniң___ kүni

___son bilan dalolatnoma yozuvi qayd etildi.
san menen akt jazio‘i dizimge alindi.

Fuqarolik holati dalolatnomalarini
yozish organi mudiri _________

Puxaraliq halati aktlerin
jazio‘ organi baslig‘i _______
Muhr
Mor



I—QQ № 0000000


(1-ilovaning davomi)

SVIDETELSTVO O ROJDENII

Grajdanin (ka) ______________________

Otets_______________________________

(familiya)

(familiya)

____________________________________

____________________________________

(imya, otchestvo)

(imya, otchestvo)

rodilsya (las) “____” _____________ goda

Mat_______________________________

(familiya)

____________________________________

____________________________________

(imya, otchestvo)

____________________________________

natsionalnost _____________________

(tsiframi i propisyu)

Mesto rojdeniya: Respublika ___________

Mesto registratsii ___________________

(naimenovaniye organa ZAGSa)

_____________________________ oblast

_____________________________________________

______________________________rayon

Data vidachi “ ____ ” _____________ goda

gorod, posyolok, kishlak _______________

Ob etom “ ______ ” _______________ goda

Zaveduщiy (aya) organom zapisi
aktov grajdanskogo sostoyaniya _________

proizvedena aktovaya zapis za № _______

Pechat


I—O'z № 0000000

(1a-ilovaning davomi)


BIRTH CERTIFICATE

Citizen ______________________________

Father ______________________________

(surname)

(surname)

___________________________________

____________________________________

(given names)

(given names)

was born on __________________________
(day, month, year in figures and words)

nationality (etnic) ______________________

____________________________________

Mother _____________________________

(surname)

____________________________________

____________________________________

(given names)

Place of birth: Republic _________________

nationality (etnic) ______________________

_______________________________region

Place of registration ____________________

(name and location of the Registry Office)

______________________________district

____________________________________

___________________________city, village.

Date of issue “ ____ ” __________________


Birth record No. ____ was filed on _________


Registrar _________________________

(day, month, year)

Seal



I—O'z № 0000000

O‘zbekiston Respublikasi
GERBI

NIKOH TUZILGANLIGI HAQIDA GUVOHNOMA

Fuqaro_____________________________________
(familiyasi)

Bu haqda______yil_______oyining______kunida

__________________________________________
(ismi, otasining ismi)

_______-son bilan dalolatnoma yozuvi qayd etildi.

tug‘ilgan vaqti______yil “ _______ ”___________

Nikoh qayd etilgandan keyin quyidagi familiyalar berildi:

tug‘ilgan joyi _______________________________

eriga ________________________________________

____________________________________________
____________________________________________

xotiniga _____________________________________

va fuqaro____________________________________
(familiyasi)

Qayd etish joyi _____________________________
(FHDYo organining nomi)

____________________________________________
(ismi, otasining ismi)

_____________________________________________

Tug‘ilgan vaqti_____yil “_______”______________

Berilgan vaqti____ yil “ _______ ”_____________

tug‘ilgan joyi ________________________________

_____________________________________________
_____________________________________________

Fuqarolik holati dalolatnomalarini
yozish organi mudiri _____________________

_____yil________________oyining________kunida

_____________________________________________

Muhr

________________________________nikoxlandilar.
(raqam va so‘z bilan)



I—O'z № 0000000


(2-ilovaning davomi)

SVIDETELSTVO O ZAKLYuChENII BRAKA

Grajdanin__________________________________
(familiya)

Ob etom “ ____ ” __________________________ goda

_____________________________________________
(imya, otchestvo)

proizvedena aktovaya zapis za № _______________.

data rojdeniya “____” _____________________ goda

Posle registratsii braka prisvoyeni familii:

mesto rojdeniya _______________________________

muju ________________________________________

_____________________________________________
_____________________________________________

jene ________________________________________

i grajdanka __________________________________
(familiya)

Mesto registratsii ____________________________
(naimenovaniye organa ZAGSa)

_____________________________________________
(imya, otchestvo)

_____________________________________________

data rojdeniya “____” _____________________ goda

data vidachi “_____” _____________________ goda

mesto rojdeniya _______________________________

_____________________________________________
_____________________________________________

Zaveduщiy (aya) organom zapisi
aktov grajdanskogo sostoyaniya _______________

zaklyuchili brak “ _____ ” __________________ goda

Pechat

_____________________________________________ _____________________________________________
(tsiframi i propisyu)





I—O'z № 0000000

(2-ilovaning davomi)


MARRIAGECERTIFICATE

_____________________________________________
(surname)

Marriage record No. _____ was filed on _____________
(day, month, year)

_____________________________________________
(given names)

In the marriage the following surnames were given to

date of birth ___________________________________
(day, month, year)

husband ______________________________________

place of birth___________________________________

wife__________________________________________

_____________________________________________
_____________________________________________

Place of registration _____________________________
(name and location of the Registry Office)

and __________________________________________
(surname)

_____________________________________________

_____________________________________________
(given names)

Date of issue “ ____ ” ___________________________

date of birth ___________________________________
(day, month, year)

place of birth___________________________________

Registrar _________________________

_____________________________________________
_____________________________________________

married on ____________________________________
(day, month, year in figures and words)

Seal

_____________________________________________
_____________________________________________



I—O'z № 0000000

O‘zbekiston Respublikasi
GERBI

NIKOH TUZILGANLIGI HAQIDA GUVOHNOMA
NEKE DYZILGENLIGI HAQQЫNDA GYO‘ALЫQ

Fuqaro Puxara ______________________________
(familiyasi/familiyasi)

Bu haqda______yil_________oyining______kunida
Bul haqqinda_____ jil_______ ayiniң____ kүni

____________________________________________
(ismi, otasining ismi/ati, Ekesiniң ati)

_______-son bilan dalolatnoma yozuvi qayd etildi.
_________-san menen akt jazio‘i dizimge alindi.

tug‘ilgan vaqti______yil “ ____ ”______________
tuo‘ilg‘an o‘aqti______jil “ ____ ”_____________

Nikoh qayd etilgandan keyin quyidagi familiyalar berildi:
Neke dүzilgennen keyin tomendegi familiyalar berildi:

tug‘ilgan joyi ________________________________
tuo‘ilg‘an jeri ________________________________

eriga yerine__________________________________

_____________________________________________
_____________________________________________

xotiniga hayalina______________________________

va fuqaro hem puxara___________________________
(familiyasi/familiyasi)

Qayd etish joyi Dizimge aling‘an jeri__________
(FHDYo organining nomi/PXAJ organiniң ati)

_____________________________________________
(ismi, otasining ismi/ati, Ekesiniң ati)

_____________________________________________

Tug‘ilgan vaqti_____yil “_______”______________
tuo‘ilg‘an jeri ________________________________

Berilgan vaqti____ yil “ _______ ”_____________
Berilgen o‘aqti ____jil“ ________ ”____________

tug‘ilgan joyi ________________________________
tuo‘ilg‘an jeri ________________________________

_____________________________________________
_____________________________________________

Fuqarolik holati dalolatnomalarini
yozish organi mudiri _____________________
Puxaraliq halati aktlerin
jazio‘ organi baslig‘i __________________

_____yil________________oyining________kunida
_____jil________________ayinin________kuni

____________________________________________

Muhr
Mor

_____________________nikohlandilar. nekelesti.
(raqam va so‘z bilan/san hem soz benen)



I—QQ № 0000000


(2a-ilovaning davomi)

SVIDETELSTVO O ZAKLYuChENII BRAKA

Grajdanin__________________________________
(familiya)

Ob etom “ ____ ” __________________________ goda

_____________________________________________
(imya, otchestvo)

proizvedena aktovaya zapis za № _______________.

data rojdeniya “____” _____________________ goda

P�sle registratsii braka prisvoyeni familii:

mesto rojdeniya _______________________________

muju ________________________________________

_____________________________________________
_____________________________________________

jene ________________________________________

i grajdanka __________________________________
(familiya)

Mesto registratsii ____________________________
(naimenovaniye organa ZAGSa)

_____________________________________________
(imya, otchestvo)

_____________________________________________

data rojdeniya “____” _____________________ goda

data vidachi “_____” _____________________ goda

mesto rojdeniya _______________________________

_____________________________________________
_____________________________________________

Zaveduщiy (aya) organom zapisi
aktov grajdanskogo sostoyaniya _______________

zaklyuchili brak “ _____ ” __________________ goda

Pechat

_____________________________________________ _____________________________________________
(tsiframi i propisyu)





I—O'z № 0000000

(2a-ilovaning davomi)


MARRIAGECERTIFICATE

_____________________________________________
(surname)

Marriage record No. _____ was filed on _____________
(day, month, year)

_____________________________________________
(given names)

In the marriage the following surnames were given to

date of birth ___________________________________
(day, month, year)

husband ______________________________________

place of birth___________________________________

wife__________________________________________

_____________________________________________
_____________________________________________

Place of registration _____________________________
(name and location of the Registry Office)

and __________________________________________
(surname)

_____________________________________________

_____________________________________________
(given names)

Date of issue “ ____ ” ___________________________

date of birth ___________________________________
(day, month, year)

place of birth___________________________________

Registrar _________________________

_____________________________________________
_____________________________________________

married on ____________________________________
(day, month, year in figures and words)

Seal

_____________________________________________
_____________________________________________



I—O'z № 0000000

O‘zbekiston Respublikasi
GERBI

O‘LIM HAQIDA GUVOHNOMA

Fuqaro ____________________________________________________________________________________
(familiyasi)

___________________________________________________________________________________________
(ismi, otasining ismi)

________________ yil________________________________ oyining___________________________ kunida

___________________________________________________________________________________________
(raqam va so‘z bilan)

____________________________________________________________________________ yoshda vafot etdi.


Bu haqda ________yil _________ oyining_______ kunida__________-son dalolatnoma yozuvi qayd etildi.

O‘limning sababi ____________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________


Vafot etgan joyi:______________________________________________________________ Respublikasi

___________________________________________________________________________________viloyati

____________________________________________________________________________________tumani

__________________________________________________________________shahri, shaharchasi, qishlog‘i


Qayd etish joyi ____________________________________________________________________________
(FHDYo organining nomi)
___________________________________________________________________________________________


Berilgan vaqti________ yil “ ______ ” _______________________________________________________


Fuqarolik holati dalolatnomalarini
yozish organi mudiri ___________________


Muhr



I—O'z № 0000000





(3-ilovaning davomi)


SVIDETELSTVO O SMERTI

Grajdanin (ka)______________________________________________________________________________
(familiya)

___________________________________________________________________________________________
(imya, otchestvo)

“ ______ ” ______________________________________________________________________________ goda

___________________________________________________________________________________________
(tsiframi i propisyu)

umer (la) v vozraste __________________________________________________________________________
Ob etom “ ______ ” ______________________________________________________________________ goda


Proizvedena aktovaya zapis za № ___________________.


Prichina smerti _____________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

mesto smerti: Respubliki_____________________________________________________________________

_____________________________________________________________________________________ oblast

______________________________________________________________________________________rayon

gorod, posulok, kishlak ______________________________________________________________________

Mesto registratsii __________________________________________________________________________
(naimenovaniye organa ZAGSa)

___________________________________________________________________________________________

Data vidachi “ _______ ” ________________________________________________________________ goda



Zaveduyuщiy(aya) organom zapisi
aktov grajdanskogo sostoyaniya ____________________________________



Pechat



I—O'z № 0000000






(3-ilovaning davomi)

DEATH CERTIFICATE

___________________________________________________________________________________________
(surname)

___________________________________________________________________________________________
(given names)

died on_____________________________________________________________________________________
(day, month, year in figures and words)

___________________________________________________________________________________________

at the age of _________________________________________________________________________________
Death record No. ___________________ was failed __________________________________________________
(day, month, year)

Cause of death: Republic ________________________________________________________________________

_______________________________________________________________________________________region

______________________________________________________________________________________ district

__________________________________________________________________________________ city, willage

Place of registration ____________________________________________________________________________
(name and location of the Registry Office)

____________________________________________________________________________________________

Date of issue _________________________________________________________________________________
(day, month, year)



Registrar _______________________




Seal



I—O'z № 0000000

O‘zbekiston Respublikasi
GERBI

O‘LIM HAQIDA GUVOHNOMA
OLIM HAQQЫNDA GҮO‘ALЫQ

Fuqaro Puxara ______________________________________________________________________________
(familiyasi/familiyasi)

__________________________________________________________________________________________
(ismi, otasining ismi/ati, Ekesiniң ati)

________________ yil________________________________ oyining___________________________ kunida
________________jil____________________________________ ayiniң______________________
kүni

__________________________________________________________________________________________
(raqam va so‘z bilan/san hem soz benen)

____________________________________________________________________________ yoshda vafot etdi.
________________________________________________________________________________ jasta oldi.


Bu haqda ___________________yil __________________________ oyining____________________ kunida
Bul haqqinda __________________jil ___________________ayiniң _____________________kүni


___________-son dalolatnoma yozuvi qayd etildi.
_______-san menen akt jazio‘i dizimge alindi.

O‘limning sababi Oliminiң sebebi____________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________


Vafot etgan joyi: Olgen jeri:_________________________________________ Respublikasi Respublikasi

_____________________________________________________________________________viloyati oblasti

______________________________________________________________________________tumani rayoni

_____________________________________________shahri, shaharchasi, qishlog‘i qalasi, posyolkasi, ao‘ili.


Qayd etish joyi Dizimge aling‘an jeri__________________________________________________________
(FHDYo organining nomi/PXAJ organiniң ati)
___________________________________________________________________________________________


Berilgan vaqti________ yil “ ______ ” _______________________________________________________
Berilgen o‘aqti________ jil “ ______ ” _______________________________________________________


Fuqarolik holati dalolatnomalarini
yozish organi mudiri ___________________
Puxaraliq halati aktlerin
jazio‘ organi baslig‘i ________________


Muhr
Mor



I—QQ № 0000000





(3a-ilovaning davomi)


SVIDETELSTVO O SMERTI

Grajdanin (ka)______________________________________________________________________________
(familiya)

___________________________________________________________________________________________
(imya, otchestvo)

“ ______ ” ______________________________________________________________________________ goda

___________________________________________________________________________________________
(tsiframi i propisyu)

umer (la) v vozraste __________________________________________________________________________
Ob etom “ ______ ” ______________________________________________________________________ goda


Proizvedena aktovaya zapis za № ___________________.


Prichina smerti _____________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________

mesto smerti: Respubliki_____________________________________________________________________

___________________________________________________________________________________ oblast

______________________________________________________________________________________rayon

gorod, posulok, kishlak ______________________________________________________________________

Mesto registratsii __________________________________________________________________________
(naimenovaniye organa ZAGSa)

___________________________________________________________________________________________

Data vidachi “ _______ ” ________________________________________________________________ goda



Zaveduyuщiy(aya) organom zapisi
aktov grajdanskogo sostoyaniya ____________________________________


Pechat



I—O'z № 0000000






(3a-ilovaning davomi)

DEATH CERTIFICATE

___________________________________________________________________________________________
(surname)

___________________________________________________________________________________________
(given names)

died on_____________________________________________________________________________________
(day, month, year in figures and words)

___________________________________________________________________________________________

at the age of _________________________________________________________________________________
Death record No. ___________________ was failed __________________________________________________
(day, month, year)

Cause of death: Republic ________________________________________________________________________

_______________________________________________________________________________________region

______________________________________________________________________________________ district

__________________________________________________________________________________ city, willage

Place of registration ____________________________________________________________________________
(name and location of the Registry Office)

___________________________________________________________________________________________

Date of issue _________________________________________________________________________________
(day, month, year)



Registrar _______________________




Seal



I—O'z № 0000000