K. P.U. 2/1984
KAEDAH KELUARGA ISLAM (BORANG DAN BAYARAN) 1983
BORANG 21
BORANG 21
NEGERI KEDAH
ENAKMEN KELUARGA ISLAM, 1979
PERAKUAN KEMATIAN
(Seksyen 45)
Di antara
............................................................................................................................. PEMOHON dan
............................................................................................................................. PENENTANG
PERINTAH / PERAKUAN
OLEH TUAN ...............................................................................................................................
KADI / KADI BESAR, KEDAH
BERTARIKH ...............................................................................................................................
Inilah disahkan bahawa orang tersebut di bawah ini telah di anggap mati.
Nama penuh ...............................................................................................................................
No. Kad Pengenalan ....................................................................................................................
Tarikh Lahir .................................................................................................................................
Jantina ........................................................................................................................................
Alamat terakhir ............................................................................................................................
Sebab kematian ...........................................................................................................................
Tempat kematian .........................................................................................................................
Saksi yang mengesahkan :
(1) ........................................................................ No. K / P .................................................
(2) ........................................................................ No. K / P .................................................
Hal-hal keadaan kematian ............................................................................................................
...................................................................................................................................................
No. rujukan ...............................................................
MOHOR
...............................................
Pendaftar/ Kadi
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