Key No.

B0060171-96070824029
FORM No.5
(See Rule 8)
tIcf km
GOVERNMENT OF KERALA
\KcImcy hIpv
DEPARTMENT OF URBAN AFFAIRS
kn^nv \Ip Xtim]\ns t]cv tImgntmSv tImtdj
Name of Local Government issuing certificate Kozhikkode Corporation
P\\ kn^nv
BIRTH CERTIFICATE
(Issued Under Section 12)

(1969se P\\acW cPnkvt{Sj BIvSnse 12mw hIppw 1999se tIcf P\\acW cPnkvt{Sj Nfnse 8mw
Nhpw A\pkcnv \IpXv).
(Issued under Section 12 of the Registration of Births and Deaths Acts, 1969 and Rule 8 of the Kerala Registration of Births and Deaths
Rules, 1999)
Xmsg ]dbp hnhc tIcf kwm\nse tImgntmSv Pnbnse tImgntmSv Xmeqnse tImgntmSv
tImtdj se (Xtim]\w) A P\\ cPndn \nv FSpnphbmsWv kmysSppp.
This is to certify that the following information has been taken from the original record of birth which is the register for (local area/local
body) Kozhikkode Corporation of Taluk Kozhikode of District Kozhikkode of State Kerala.
---t]cv/ Name : t]cv cPn sNbvXnn / Name Not Registered
---B/s]/ Sex B/ Male
:
---P\\ XobXn/ Date of Birth : 28/06/1996
TWENTY EIGHT/JUNE/ONE THOUSAND NINE HUNDRED NINETY SIX
---P\\ ew/ Place of Birth :
AtimIm tlmkv]n, tImgntmSv/

Asoka Hospital , Kozhikode

---amXmhns t]cv / Name of Mother SAJILA.K.P
:
---]nXmhns t]cv/ Name of Father
: P.P. KUMARAN
IpnbpsS P\\ kabv : *** e`ya
amXm]nXmfpsS tahnemkw

Address of the parents at the time of : *** Not Available

birth of the child
amXm]nXmfpsS ncamb : tcJsSpnbnn
tahnemkw

Permanent address of parents : Puthan Peeikayil,kakkattil

cPnkvt{Sj \/ : 2788/1996 cPnkvt{Sj XobXn/ : 08/07/1996

Registration Number Date of Registration
*** A tcJIfn IpnbpsS P\\ kabv amXm]nXmfpsS tahnemks
---A`n{]mbpdnv/ Remarks (if any) : kw_n tImf DsSpn

*** The original records do not contain the column relating to the address of the parents at
the time of birth of the child.
---\Ip XobXn/ Date of Issue : 14/08/2017 (16:47) Last Updated on 21/05/2015 (10:34)

\Ip A[nImcnbpsS tahnemkw/

: Registrar of Births and Deaths ,
Address of the issuing authority
Kozhikkode Corporation

Ensure Registration of Every birth and death

Hmtcm P\\hpw acWhpw cPn sNbvXpshv DdphcppI
This certificate is computer generated and does not require any Seal/Signature in original
The Govt. vide G.O.(Ms) No.202/2012/LSGD dated 25/07/2012 has approved this certificate as a valid document for all official purposes
Authenticity of this certificate can be verified at www.cr.lsgkerala.gov.in. The Key Number is unique to each event.
Software developed and supported by Information Kerala Mission.
Certificate printed before the last updated date is invalid
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