Form5

9TRET T (f -<) èfar

GOVERNMENT OF MADHYA PRADESH, INDIA

DEPARTMENT OF PLANNING, ECONOMICS & STATiSTICS

Regstrai
BIRTH CERTIFICATE
ITTATTq7
(ISSUED UNDER SECTION 12/17 OF THE REGISTRATION OF, BIRTH & DEATH ACT.1969 AND RULE 8/13 OF THE MADHYA
PRADESH REGISTRATION OF BIRTH & DEATH RULES 1999.)
(ST s r R T 3fUAra, 1969 erT 12/17 r aca wa A F FrTfAu7, 1999 f 7 8/13 sraara artt aa ura

THIS IS TO CERTIFY THAT THE FOLLOwING INFORMATION HAS BEEN TAKEN FROM THE ORIGINAL RECORD OF BIRTH WHICH
IS REGISTERED IN MUNICIPALITY sINGRAULI NAGAR NIGAM OF STATE MADHYA PRADESH, INDIA

Reg No / TstarUT FE 0396 / SING/0002159/3000031252/2018 Date of Reg oterUT TTU: Nov 1, 2018

Name of Child T : PANKAJ KUMAR SHAH Sex of Child TeT:Male

Place of Birth / RIA: SINGRAULI Date of Birth 7 RT: June 4, 2004

Mother's Name AT ATH Father's Name MaT ATT:

Mrs./tTctVANDANA DEVI SHAH Mr.1t KAILASH PRASAD SHAH

UID No. of Mother HAT ZHT^ST 7:390889686115 UID No. of Father YTST TaR : 818811782986
SSSM ID of Mother I HTAI I AT TR: SSSM ID Father T TFTU ar

Parent's Address at the time of Birth / H HHY HIAT-f9EAT T T Permanent Address of Parents / 3H11HTTY7 RI T

33/716 33/716

33 33

NAVJEEVAN VIHAR NAVJEEVAN VIHAR

SEC-03 SEC-03
SINGRAULI SINGRAULI

Date of Certificate Issued/ 3nt faf

Hospital (Institute) Name ifeea (HFRIF) FIT

3SI11 Friday, November 2, 2018

Order No 3èr 146

Date of Order 3mdr ain October 25, 2018

taky sigrel ty HanA t

This is a Computer generated Certificate. This Certificate is a valid legal documenl for all oficial puposes"

"Ensure Registration of every Birth and Death."

THE AUTHENTICITY OF THE CERTIFICATE CAN BE VERIFIED FROM THE WEBSITE www.mpenogarpalika.gov.in