सं.

1 उर देश सरकार प-5

NO. 1 GOVERNMENT OF UTTAR PRADESH FORM-5
चकसा एवं वाय वभाग
DEPARTMENT OF MEDICAL AND HEALTH

ाम पंचायत गौसह

GRAMA PANCHAYAT GOUSIHA

जम माण-प
BIRTH CERTIFICATE

(जम मृयु रिजकरण अधनयम, 1969 क धारा 12 / 17 तथा उर देश 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 UTTAR PRADESH
REGISTRATION OF BIRTHS & DEATHS RULES 2002)

यह मािणत कया जाता है ननलिखत सूचना जम के मूल अभलेख से ल गई है जो क ाम पंचायत गौसह तहसील गडा िजला गडा राय/संघ देश
उर देश, 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 GRAMA PANCHAYAT GOUSIHA OF TAHSIL/BLOCK GONDA OF DISTRICT GONDA OF STATE/UNION TERRITORY UTTAR PRADESH, INDIA.

नाम / NAME: ALI HUSAIN लंग / SEX: पुरष / MALE

जम तथ / DATE OF BIRTH: जम थान/ PLACE OF BIRTH:

01-02-2003 DISTRICT - GONDA,
FIRST-FEBRUARY-TWO THOUSAND THREE BHAT PURWA,GONDA , GONDA,
UTTAR PRADESH

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

KITABUNNISHA SALEEM

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

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:
MOHALLA BANDARAHA, SHIVAJIPURAM, MOHALLA BANDARAHA, SHIVAJIPURAM,
BHINGA, , BHINGA, SHRAWASTI, UTTAR PRADESH- 271831 BHINGA, BHINGA, SHRAWASTI,
UTTAR PRADESH- 271831

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

B-2021: 9-34354-000172 21-08-2021

टपणी / REMARKS (IF ANY):

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जार करने क तथ / DATE OF ISSUE: जार करने वाला ाधकार / ISSUING AUTHORITY :
21-08-2021
रिजार (जम एवं मृयु)
REGISTRAR (BIRTH & DEATH)
ाम पंचायत गौसह
GRAMA PANCHAYAT GOUSIHA

UPDATED ON :
21-08-2021 19:26:26

"THIS IS A COMPUTER GENERATED CERTIFICATE. "

" 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 "