10 skrócony akt zgonu EN (1)

CERTIFIED TRANSLATION FROM POLISH

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[The copy of the document which is an integral part of this translation has been submitted to translate. The document consists of one page with the national emblem of the Republic of Poland. *Translator’s remark*.]-/-

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[The national emblem of the Republic of Poland]-/-

THE REPUBLIC OF POLAND -/-

Voivodeship – małopolskie -/-

Urząd Stanu Cywilnego [Registry Office] in Kraków -/-

ABBREVIATED CERTIFICATE OF DEATH -/-

I. Particulars of the deceased: -/-
1. Family name – Nowak -/-
2. Name (names) – Stanisław -/-
3. Name of birth – Nowak -/-
4. Marital status – married -/-
5. Date of birth – seventh September, one thousand nine hundred twenty (07.09.1920)-/-
6. Place of birth – Gdynia -/-
7. Residence – Kraków, ul. Floriańska 1/1 -/-
II. Date and place of death: -/-
1. Date of death – twentieth October, two thousand and five (20.10.2005) -/-
2. Place of death – Kraków -/-
III. Particulars of the spouse of the deceased: -/-
1. Family name – Wacnik -/-
2. Name (names) – Marianna -/-
3. Name of birth – Świercz -/-
IV. Particulars of parents of the deceased: -/-
1. Name (names) of father of the deceased – Jakub -/-
2. Name of birth of father of the deceased – Nowak -/-
1. Name (name) of mother of the deceased – Anna -/-
2. Name of birth of mother of the deceased – Kowalska -/-

The above particulars have been confirmed to be a true copy from the official death record No. 1234/2005 -/-
Kraków, date: 31
st October, 2005 -/-
[a rectangular stamp reading]: Registrar General of the Registry Office [a handwritten illegible signature] -/-
stamp duty
-/-
[a round seal with the national emblem of the Republic of Poland and illegible circumscription] -/-
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I, the undersigned, Monika Mikocka, sworn translator and interpreter of English and Polish registered in the register of sworn translators and interpreters kept by the Minister of Justice, entry number TP/nn/rr, hereby certify this to be true and accurate translation of the copy in the Polish language presented to me. Kraków, 09.04.2014, Register number: 10/2014.









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