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 अजनावर
GRAMA PANCHAYAT AJANAVAR

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 अजनावर तहसील बसौल िजला बदायूँ 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 AJANAVAR OF TAHSIL/BLOCK BISAULI OF DISTRICT BUDAUN OF STATE/UNION TERRITORY UTTAR PRADESH, INDIA.

नाम / NAME: PRIYANSHU लंग / SEX: महला / FEMALE

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

24-08-2007
TWENTY-FOURTH-AUGUST-TWO THOUSAND SEVEN AJANAVAR,BISAULI , BUDAUN,
UTTAR PRADESH

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

USHA SIKANDAR

आधार नंबर / MOTHER'S AADHAAR NO: आधार नंबर / FATHER'S AADHAAR NO:
XXXXXXXX8861

बचे के जम के समय माता-पता का पता / ADDRESS OF PARENTS AT THE TIME OF माता-पता के थायी पता/ PERMANENT ADDRESS OF
BIRTH OF THE CHILD: PARENTS:
DEIPUR, IBRAHIMPUR,
ATRAURA, ATRAURA, , TANDA, AMBEDKAR NAGAR, UTTAR PRADESH- 224234 DEIPUR, IBRAHIMPUR,
ATRAURA, ATRAURA, TANDA, AMBEDKAR NAGAR,
UTTAR PRADESH- 224234

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

B-2021: 9-10332-000422 15-10-2021

टपणी / REMARKS (IF ANY):

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जार करने क तथ / DATE OF ISSUE: जार करने वाला ाधकार / ISSUING AUTHORITY :
15-10-2021
रिजार (जम एवं मृयु)
REGISTRAR (BIRTH & DEATH)
ाम पंचायत अजनावर
GRAMA PANCHAYAT AJANAVAR

UPDATED ON :
15-10-2021 16:00:48

"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 "