Receipt Date Y M D Release Date Y M D

Notification of Death S. No.:

Dispatch Date Y M D
Chief’s Stamp
Notification Date Y M D
S. No.:
Document Family Investigation Survey Attachment Residence Notification
Chief Survey Register Form Card 9-2
(Notified To) 19-3

First Name Last Name

✓ Male
(1)
(2)
Name Noboru Karashima Female
In case of death within AM
(3) Date of Birth 1933 Y 4M 24 D 30 days of birth, please Hr Min
mention the birth date PM
and time as well
AM
(4) Date and Time of ✓
Death
2015 Y 11 M 26 D 9 Hr 13 Min
PM

(5) Location of Death Okamoto, Kamakura City, Kanagawa Prefecture. ZIP: 1370-1

Address Jomyoji, Kamakura City, Kanagawa Prefecture. ZIP: 3-3-38

(6) {Registered
Residence} Name of Head of the Family: Noboru Karashima
Domicile of Hongo, Bunkyo Ku, Tokyo, 7-3
(7) Origin
{In case of Foreigner, Head of the Family: Noboru Karashima
please write only the
Nationality}

(8) Spouse of the

Deceased ✓ Yes (73 Years) No { Unmarried Widower Divorcee}
(9)
1. Households involved in agriculture only or agriculture and other work
2. Households which are self-employed or involved in professions, like commerce and
service industries, etc.
Main 3. Households of permanent (regular) workers, working in companies or private shops
(excluding government agencies), whose number of employees is between 1 to 99
occupation of employees (daily or contractual employees with contracts of less than 1 year, are 5)
(10) the household 4. Households of permanent (regular) workers and executives of company groups that do
at the time of not fall in above “category 3”. (daily or 5 contractual employees with contracts of less
death than 1 year are 5)
5. Households with other works which do not fall in the above categories of "No.1 to No.4".
6. Households where no one is working
Occupation and (Please write in this column only if the deceased died in between 1st April of the year of National
(11) Industry of the Census till 31st March working day of the following year)
deceased
Occupation: Industry:
Others

1. Relatives living together 2. Relatives who do not live together 3. Housemate 4. House Owner
5. Land owner 6. House Manager 7. Land manager 8. Head of Municipal Office 9. Guardian
10. Curator 11. Limited Guardian 12. Voluntary Guardian

Address:
Notifier

Domicile:
Head of the Family:
Signature:
Stamp
Date of Birth Y M D
Case File No. ●Notifier must carry the seal used here with himself.
 Fill in the details using black ball pen or ink pen

Death Certificate
This Death Certificate may be used as a data for statistics related to death in Japan, therefore please write in detail as much as possible

1．Male
Name Noboru Karashima Date of Birth 1933 Y 4 M 24 D
2．Female

Date & Time of 2015 Y 11 M 26 D AM・PM 09 hr 13 min

Death

1. Hospital 2. Clinic 3. Nursing & Healthcare Facilities for the Elderly 4. Birth Centre
Category of Location of Death
5. Elder Care Facility 6. Home 7. Others
(12) Location (and its
(13) Category) of Death Location of Death (Address) Okamoto, Kamakura-city, Kanagawa-ken, ZIP: 1370-1

Facility Name Iryohojin Okinawa Tokushukai, Shonan Kamakura General Hospital

Cause of Death (a) Direct Cause of Death Acute Myelocytic Leukemia Time period from 14 Days
the onset of injury
♦ Please do not write heart (b) Cause of (a) till death
failure, respiratory failure, etc. as
the terminal state of disease at I ♦ Please write in
both column I and column II. (c) Cause of (b) the format of year,
month, day etc.
♦ In column 1, please write the (d) Cause of (c)
However, if less
(14) name of the injury or disease than one day,
please write in
that affected the death most in Name of the injury, etc. which hours, minutes etc.
may not be directly related to the
the order of medical causality.
II cause of death, but has (Eg 1 year 3
influenced the injury, mentioned months; 5 hours 30
♦ Please describe the name of minutes)
in column I
injury / illness in column 1 in

each column.
1 No 2 Yes Body Part and the Major Findings Y M D
Surgery

Surgery Date
However, if the no. of columns is
insufficient, write the rest in a
sequential order of medical
1 No 2 Yes The Major Findings
Auto
psy

causality in the (E) column.

1. Death by Disease and Natural Death

Death by Accident [ 2. Road Accident 3. Falling Down 4. Drowning 5. Injuries due to Smoke, Fire or Flame 6 Suffocation 7 Poisoning 8
Others ]
(15)
Type of Death Cause
External Causes of Death

Other External Causes of Death [ 9. Suicide 10. Murder 11. Other External Factors ]
12. Unknown Death

In case of an injury Y M D AM・PM hr min Location where Address:

Additional Details for injury occurred
External Causes of
Type of Location where 1 Housing 2 Factory & Construction Site 3 Road
(16) Death
injury has occurred 4 Others ( )
♦Please write even in case
of hearsay or presumption.
Means and Status

Additional information Body weight at the time of birth Single/ Multiple Births No. of Weeks of Pregnancy
in case of death due 1. Single Birth 2. Multiple Births (Baby No. _ out of _ Weeks
to disease within 1 Grams _ babies)
(17) year after birth
Maternal condition or abnormality during pregnancy and Mother’s Date of Results till last pregnancy
delivery birth No. of Babies Born
1. No 2. Yes ( ) 3. Unknown No. of Stillborn Babies

Other noteworthy things

(18)

Diagnosis as per above Kamakura City, Okamoto 1370-1 Diagnosis Date: 2015 Y 11 M 26 D

Iryohojin Okinawa, Tokushukai, Date of Issue of Diagnosis Certificate: 2015 Y 11 M 26 D

Shonan Kamakura General Hospital
(19)
Name and address of hospital,
Tel: 0467-46-1717
clinic, nursing home, health care facility,
etc. or doctor's address
(Name) Doctor Sato1 Seal

(Note) Death Certificate issued by a hospital or clinic may also be acceptable, however, it is recommended to use this death certificate as much as possible.

1
Japanese character of the Doctor’s name is not properly visible, so I could identify only his surname and his first name is unknown.
The Will

Below is the Will of the Testator, Noboru Karashima.

1. Testator has made his wife, Takako Karashima (born on 7th January 1942) to succeed all
his wealth.

2. Testator has designated attorney, Mr. Shin Kikuchi (Mori Hamada Matsumoto Law Offices,
Marunouchi Park Building, 2-6-1 Marunouchi, Chiyoda Ku, Tokyo 100-0005, born on 17th
January 1960) as the enforcer of his Will.

3. Testator has conferred below authority to the Enforcer of this Will.

(1) Transfer, cancel or refund of real estate, saving deposits, stocks and other inherited
properties
(2) Nominate a Substitute or Assistant, if deemed necessary, for enforcing this Will
(3) Perform any other disposition, necessary for enforcement of this Will

Additional Remarks

1. For properties, refer to the Property section of the annexure.

2. The Testator thinks of his three children (Akira, Satoshi, Hiroshi) fairly and wished to divide his
properties equally among them, however, in order to secure his wife Takako’s old age, he has
decided to give all his properties to his wife, Takako.

1st July 2014

3-3-38 Jomyoji Kamakura City
Testator: Noboru Karashima
(Noboru Karashima)

This is a coloured
photocopy
Above is the image of Bank Account details of Mrs. Takako Karashima. And below the same
details are provided in English.