Ref. No.
: BA2021190091400018GP-001
Form No. 1 BIRTH REPORT
Legal information
1. Date of Birth: 04-10-2021
2. Sex: Male
3. Name of the child, if any:
4. Name of the father:
UID No of Father (if any):
5. Name of the mother:
UID No of Mother (if any):
6. Address of parents at the time
of Birth of the Child:
Bara Suzapur, Kaliachak - I,
Maldah , West Bengal,
7. Permanent address of
parents:
Bara Suzapur, Kaliachak - I,
Maldah , West Bengal,
8. Place of birth:
Bara Suzapur, Kaliachak -
I, Maldah , West Bengal
9. Informant’s name:
MUKADDARSK
Signature or left thumb
mark of the informant
Date: 04-10-2021
TO BE FILLED BY THE REGISTRAR
Registration No.:
Registration Date:
Registration Unit: GRAMA
PANCHAYAT SUJAPUR
Town/Village: Bara Suzapur
District: Maldah
Remarks (if any):
Name and Signature of the
Registrar
BIRTH REPORT Form No.1
Statistical information (See Rule 5)
10. Town or Village of Residence 16. Age of the mother (in completed
of the mother: years) at the time of first
marriage:0
a) Name of 17. Age of the mother (in completed
Town/Village:Bara Suzapur years) at the time of this birth: 0
b) Is it a town or 18. Number of children born alive to
village:Village the mother so far including this
child: 1
c) Name of District: Maldah 19. Type of attention at delivery:
Relatives or others
d) Name of State: West
Bengal
11. Religion of the Family:Islam 20. Method of Delivery:
Any other religion: 21. Birth Weight (in kgs.): 1.000
12. Father’s level of education:
Primary 22. Duration of pregnancy (in weeks):
13. Mother’s level of education:
Primary
14. Father’s occupation:
Workers not classified
elsewhere
15. Mother’s occupation:
Non worker
District: Maldah Registration No:
Sub-District: Kaliachak - I Registration Date:
Town/Village: Bara Suzapur Date of Birth: 04-10-2021
Registration Unit: GRAMA Sex: Male
PANCHAYAT SUJAPUR
Place of Birth: House
Name and Signature of the Registrar
NOTE: - Please forward print out of this reporting form duly signed along with supporting documents to
the REGISTRAR (BIRTH & DEATH), GRAMA PANCHAYAT SUJAPUR, VILLAGE/TOWN: BARA
SUZAPUR, SUB-DISTRICT: KALIACHAK - I, DISTRICT: MALDAH , STATE: WEST BENGAL