UNCLASSIFIED US Department of State Case No Doc No 005191419 Date 09 14 2012 IN PART Baj J 037352 M snarorEAg'niadfs niEREQi'evErI UNCLASSIFIED US Department of State Case No F-2011-25503 Doc No 005191419 Date 09 14 2012 US Department of State Case No Doc No C05191419 Date 09 14 2012 73 5 215 1% 75 1 21 august 9 95 1433 ubgf jXE f b 31 433344 Mama-ages a Hts 3393324339 aha nata- 13 3 Ebb 1 15 NH w i 7 433 E al 'e az 1 1 04 738913833 1134 13 44331 211 7 J L py kz 11 new any m ber l 45 pill lilqg 143 I 5 41ng I 86 933 3 -- @fxm- fill - W UNCLASSIFIED US Department of State Case No F-2011-25503 Doc No C05191419 Date 09 14 2012 US Department of State Case No F-2011-25503 Doc No 005200799 Date 09 14 2012 -5- IN Bel LS No 08-2012-0384-B Arabic English SK Republic of Yemen Death Certificates Abdul Rahman Al- Awiaki US Department of State Of ce of Language Services Translating Division TRANSLATION Form number 3 Alif Mim Fees 120 Riyals 037352 Ta 2010 Of cial Emblem Republic of Yemen Ministry of Interior Civil Status Authority and Civil Registry Death Certi cate Civil Status Department The Main Of ce District Governorate Sanaa Sharon Ahmad Senior Reviewerj UNCLASSIFIED US Department of State Case No F-2011-25503 Doc No 005200799 Date 09 14 2012 UNCLASSIFIED US Department of State Case No F-2011-25503 Doc No C05200799 Date 09 14 2012 -6- Rectangular stamp showing a registration number of 19363 and a date of 11 14 2011 Rectangular stamp showing an illegible signature and the date 11 14 2011 Deceased Data Deceased s Full Name First name Abdul Rahman Father s Name Anwar Grandfather s Name or Surname Al- Awlaki Sex male female Male Religion Muslim Nationality US Citizen Date of Birth Ninety Five Death Data Date of death written in letters October Fourteenth Two Thousand and Eleven A D Place of Death Village or Town District Governorate State Shabwa Marital Status Single Occupation Student UNCLASSIFIED US Department of State Case No F-2011-25503 Doc No C05200799 Date 09 14 2012 UNCLASSIFIED US Department of State Case No F-2011-25503 Doc No 005200799 Date 09 14 2012 Usual Place of Residence Address Village Town District Governorate State Shabwa Identity Card Data Kind of Card Number Date of Issue Place of Issue Mother s Data First Name I B6 Father s Name Grandfather s Name Surname Civil Registry Record Name of Department Number Date The death was recorded in the Death Registry Book number 1 under number 950 on 11 14 2011 AD In the Civil Status Department of the City of The Main Of ce UNCLASSIFIED US Department of State Case No Doc No C05200799 Date 09 14 2012 UNCLASSIFIED u s Department of State Case No F-2011-25503 Doc No 005200799 Date 09 14 2012 1 District illegible Governorate Sanaa Name of the Registrar Adnan Mohammed His Signature illegible signature Name of the Director of the Civil Status Department Colonel Ali Khayran His Signature illegible signature Seal illegible round imprint seal CERTIFICATION OF W013 Iher-aby ear-em that theahove translation WormaUs We I 2 4 am Lit 6 2 'k 1 1 Chief Tammany Diviatm UNCLASSIFIED US Department of State Case No F-2011-25503 Doc No C05200799 Date 09 14 2012 US Department of State mm _E i Report of Death of an American Citizen Abroad I Post 8 date ofissuet SSA No Name in Full jhdulrahm n tyang tulggi _Agc 16 Date and Place of Birth #133th folorado __Uni_ted _Statcs _O_fr r_ngiczt Evidence of US Citizenship Regularfajganj7i019u3p Issued O__n _March 04 200_3 AddressinU S A 33 Permanent or Temporarv Address Abroad _Y_e_men__ Date of death Ii @911 Month Day Hour on inure Year Place ofdeath 1 1mg 7Num t r cr andEree t 0_r or hotel City Country Cause of death __Unltn_ow_t_t Includinghutho y for statement Ith-ys'tcnm mat scle fufnrm'e and otTetuI title tram a Disposition of the remains Unknown a g Local law uovernmu dismterment of Tcmalns pl OVIdeS that 34 1 alga EX 1 99 11 73 Person or of cial responsible for custody of effects and accounting therefore Traveling residing abroad with relatives or friends as follows NAME ADDRESS In formed by telegram or telephone ADDRESS DATE NOTIFIED 31113012011 Copy ofthis report sent to alum aletwl temuv ADDRESS DATE SENT 4 Notification or copy sent to Federal Agencies SSA VA CSC Other State Agency 5 3 The original copy of this document and information concerning the effects are being placed in the permanent les of the Department of State Washington D C 20520 53 Remarks E I 1 Continue on reverse REVIEW Sharon Ahmad Senior R-ev'ewer - St_ephanie Bunce of the United States ol Ametica Consul 05-2060 For Additional Certi ed Copies see Formerly OF-I 80 09-2004 UNCLASSIFIED US Department of State Case No Doc No 005191306 Date 09 14 2012 UNCLASSIFIED 08 Department of State Case No F-2011-25503 Doc No 005191306 Date 09 14 2012