ÊÊÊÊLœTÊà Form No.

6
ÊTŽIYÊâ>~ÊLXƫtB (See Rule 8)

IMY…JXžÊ6O˜
Goverment of Tamil Nadu
Department of Municipal Administration & Water Supply
Salem City Municipal Corporation / ^DQÊMXJBOXyDY
DEATH CERTIFICATE - 8P~©ÊDX}PYI…Ê
(Issued Under Section 12/17 of the registration of Births and Deaths Act. 1969 and Rule of 8 of Tamil Nadu Registration of Birth and Death Rules 2000)

This is to Certify that the following information has been taken from the original record of DEATH which is the register
for DIV-61 of SALEM CITY MUNICIPAL CORPORATION of Taluk SALEM NORTH of District SALEM of State TAMIL NADU
ÊÊÊÊÊÊÊBZ…BzGÊIBTƒB„ÊIMY…JXžÊMXJYQÊ^DQÊMXTyGÊ^DQÊTGt”ÊTyGÊ^DQÊMXJBOXyDYÊ
LŽƬºÊ<zÊØÊ>Ê^Dƫ|IÊ6DƒÊ8P~©ÊLIY^TyœQY¯|¢Ê<žtB~LyG_TÊ<KÊDX}PYI…ÊTSuB~LžBY}P¢Ø

Name / ]LNƫ TŽMQX

UID Number of Deceased/8P|ITƬ}Ê7IXƫÊ<z XXXXXXXX0328

Name of Mother / IXNŽ}Ê]LNƫ BMQX

UID Number of Mother/ IXNŽ}Ê7IXƫÊ<z XXXXXXXXXXXX
Name of Father / I|_INŽ}Ê]LNƫ O{IYK^Tƒ
UID Number of Father / I|_INŽ}Ê7IXƫÊ<z XXXXXXXXXXXX

Name of Wife /Name of Husband/ M_KTŽÊ MBX^IT}

]LNƫÙBHTƫÊ]LNƫ

UID Number of Wife/UID Number of Husband/ XXXXXXXX7554

M_KTŽÊ7IXƫÊ<zÙBHTƫÊ7IXƫÊ<z
Age / TN¢ 38
Sex / LXQYK ]Lz
Date of Death / 8P|IÊ^IIY 17-Oct-2017
Place of Death / 8P|IÊ8G 6O˜Ê^MXB}ʔMXOMuBRÊ
M¯{¢TtÊBƒµƬÊM¯{¢TM_K^DQ
-
--

Permanent Residential Address of the Deceased / 5/968Ö]T„_RNBºzG}Ê]I¯

8P|ITƬ}ÊJY_QNXKÊT“yžÊ«BTƬ ™OMuBQÒ6ÓÖÊ^DQ
636005
Address of the Deceased at the time of Death / 5/968Ö]T„_RNBºzG}Ê]I¯
8P~LŽ}Ê^LX¢ÊTDY~LŽGÊ«BTƬ ™OMuBQÒ6ÓÖÊ^DQ
636005
Registration No / LIYºÊ<z 049/2017/61/03300
Date of Registration / LIYºÊ]D€IÊ^IIY 23/Oct/2017
Remarks(If any) /
Date of Issue / ^IIY 22/Oct/2018

Signature and Address Of Issuing Authority

DX}PYI…Ê6R~LTƬ}Ê_B]NX~L
Registrar, Birth & Death: ^DQÊMXJBOXyDY

No disclosure shall be made of particulars regarding the cause of death as entered in the Register
8P~©ÊLIY^TyœƒÊ<¸I~LyGÊ8P~LŽ}ÊBXOHÊ<_T­Ê8~L”IYNŽƒÊ]TRNŽGLGt•GX¢
(See Provision to Section 17( 1 ) - LŽƬºÊÊÛáÒÊÛÊÓ×}ÊBX~©_ONŽ}LœÓ

ENSURE REGISTRATION OF EVERY BIRTH AND DEATH LŽP~©ÊÙÊ8P~©~ÊLIYTŽ_KÊ:²IYÊ]D€T“ƫ

Certificate No : DCP/049/2018/0004849
Note:This Certificate is computer generated and does not require any seal/signature the authenticity of this certificate can be verified
https:// tnurbanepay.tn.gov.in .The Registration number is unique to each Death.