सं.

1 हरयाणा सरकार प-5

NO. 1 GOVERNMENT OF HARYANA FORM-5
वाय सेवाएं वभाग
DEPARTMENT OF HEALTH SERVICES
नगर पालका फतेहाबाद
MUNICIPALITY FATEHABAD

जम माण-प
BIRTH CERTIFICATE

(जम मृयु रिजकरण अधनयम, 1969 क धारा 12 / 17 तथा हरयाणा जम मृयु रिजकरण नयम, 2002 के नयम 8/13 के अंतगत जार कया गया
)
(ISSUED UNDER SECTION 12/17 OF THE REGISTRATION OF BIRTHS & DEATHS ACT, 1969 AND RULE 8/13 OF THE HARYANA REGISTRATION OF
BIRTHS & DEATHS RULES 2002)

यह मािणत कया जाता है ननलिखत सुचना जम के मूल अभलेख से ल गई है जो क नगर पालका फतेहाबाद तहसील फतेहाबाद िजला फतेहाबाद
राय/संघ देश हरयाणा, भारत के रिजटर म उिलिखत है ।
THIS IS TO CERTIFY THAT THE FOLLOWING INFORMATION HAS BEEN TAKEN FROM THE ORIGINAL RECORD OF BIRTH WHICH IS THE REGISTER
FOR MUNICIPALITY FATEHABAD OF TAHSIL/BLOCK FATEHABAD OF DISTRICT FATEHABAD OF STATE/UNION TERRITORY HARYANA, INDIA.

नाम / NAME: MANSI लं ग / SEX: पु रष / FEMALE

जम तथ / DATE OF BIRTH:

जम थान/ PLACE OF BIRTH:
22-01-2018 CIVIL HOSPITAL PATNA
TWENTY TWO-JANUARY-TWO THOUSAND EIGHTEEN

माता का नाम / NAME OF MOTHER: पता का नाम / NAME OF FATHER:

GUNJAN RAMCHANDER

आधार नंबर / MOTHER'S AADHAAR NO: आधार नंबर / FATHER'S AADHAAR NO:
XXXXXXXX1244

बचे के जम के समय माता-पता का पता / ADDRESS OF PARENTS AT THE TIME माता-पता के थायी पता/ PERMANENT ADDRESS OF PARENTS:
OF BIRTH OF THE CHILD:
VPO KUKRANWALI, VPO KUKRANWALI,
VPO KUKRANWALI , FATEHABAD, FATEHABAD, HARYANA- 125050 VPO KUKRANWALI , FATEHABAD, FATEHABAD,
HARYANA- 125050

पंजीकरण संया / REGISTRATION NUMBER: पंजीकरण तारख / DATE OF REGISTRATION:

B-2018: 6-90089-001864 29-10-2018

टपणी / REMARKS (IF ANY):

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जार करने क तथ / DATE OF ISSUE: जार करने वाला ाधकार / ISSUING AUTHORITY :
15-12-2018
रिजार (जम एवं मृयु)
REGISTRAR (BIRTH & DEATH)
नगर पालका फतेहाबाद
MUNICIPALITY PATNA

UPDATED ON :
29-10-2018 00:00:00

"THIS IS A COMPUTER GENERATED CERTIFICATE WHICH CONTAINS FACSIMILE SIGNATURE OF THE ISSUING AUTHORITY"
" THE GOVT. OF INDIA VIDE CIRCULAR NO. 1/12/2014-VS(CRS) DATED 27-JULY-2015 HAS
APPROVED THIS CERTIFICATE AS A VALID LEGAL DOCUMENT FOR ALL OFFICIAL PURPOSES".

" येक जम एवं मृयु का पंजीकरण सुनचत कर" / ENSURE REGISTRATION OF EVERY BIRTH AND DEATH "