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(Translation)

Official Emblem

Thor.Ror.14/2

Certified Civil Registration Data base Date : . Registration Office :

Name : Identification No : Date of Birth : Sex :

Name of natural mother : Nationality : Name of natural father : . Nationality : Address : .

House Code No : Addendum

Nationality : Status :

Date of living in :

Certified Correct Civil Registration Data base

Registrar

Certified correct translation Signed . )

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