Verificat identitatea solicitantului

nregistrat la nr._________________

Ofier de stare civil,

din______________________________

L.S.

DOMNULE PRIMAR,

Subsemnatul_______________________________, fiul lui _______________________

i al ______________________________, domiciliat n ________________________________,
str. __________________________________________, nr. _____, bl. ____________, sc._____,
et, ____, ap. _____, judeul ________________________________, posesor al crii/buletinului
de identitate seria _____, nr. ___________, eliberat de _________________________, v rog
s binevoii a-mi elibera certificatul de ____________________________, n care sens fac
urmtoarele precizri:
- m-am (s-a) nscut la data de__________, n localitatea___________________________,
judeul ________________________.
- m-am cstorit cu_____________________________________, la data de __________,
n localitatea __________________________________, judeul _________________________.
- numitul____________________________________, a decedat la data de __________,
localitatea __________________________________, judeul __________________________.
Vechiul (vechile) certificat (e) mi-a (mi-au) fost furat (e), distrus (e), pierdut (e) n
urmtoarele mprejurri __________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________________________________________________.

DATA

SEMNTURA

_____________________

_________________________________

Eliberat certificat de:

Natere seria______, nr. _______________
Cstorie seria______, nr. _______________
Deces seria______, nr. _______________
Data ________ 20 ____
Ofier de stare civil delegat,
___________________________________
Am primit certificatele solicitate
Semntura

DOMNULUI PRIMAR AL MUNICIPIULUI FETETI, JUDEUL IALOMIA