D.P.H. – 368 Form No.

10
(See Rule 9)

DEATH CERTIFICATE
Chief Registrar (Birth & Death)
Punjab, Chandigarh
It is certified that the Information written below has been taken from the original Birth Record
which is registered in the Register of Local Registrar Birth & Death MUNICIPAL
COMMITTEE, SANGRUR, Tehsil SANGRUR District SANGRUR State Punjab.

Name : Amarjeet Singh Permanent Address : Magzine Street

Father’s Name : Hari Singh Sangrur (Pb)

Nationality : Indian

Sex : Male

Date of Death : 17/02/1991 Registration No. : 65

Place of Death : Sangrur Date of Registration : 22/02/1991

Certificate preparing person’s Signature Certificate issuing person’s Signature

Name : Kulwant

Name : Jaswant Singh Stamp

Local Registrar, Birth & Death

Municipal Committee, Sangrur

Date : 11/04/1991

Note :- This Certificate (Death) has been issued under the Birth & Death Registration Act 1969
(India Govt.) Section 12/17. What cause of death has been told in the Death register, That
information will not be given in the Death Certificate