State of Israel 							     Ministry of the Interior

Civil Register’s Registration Statement

Surname	Troll		Given Name	Moomin	
					
Father’s Given Name	Moominaba				
					
Mother’s Given Name	Moominima				
					
Sex	Male		Identity Number	1 2345678 9	
					
Nationality	Jewish		Religion	Jewish	
					
Date of Nationality Alteration			Date of Religion Alteration		
					
Personal Status	Single		Date of Personal Status Alteration		
					
Country of Birth	Israel				
					
Date of Birth (Jewish Calendar)	1st day of Tishrei 5702		Date of Birth (Gregorian Calendar)	September 1st 1945	

Address:  Jerusalem   Moominvalley   1       1234567
Date of Entrance to Present Address:  January 1sth 1933
Notes:

I hereby certify that the above statement is a true statement as given by the Civil Register
This Document has been issued subject to paragraph 29 of the Civil Register Law 1965 
At the Chamber of Civil Register in Jerusalem
On the    17th day of Adar II 5776            March 27th 2016

Arnolds Moran Tzipora
Coordinator
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Name and Signature of the Clerk	State of Israel
Ministry of the Interior
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Office's Stamp