Form-5

GOVERNMENT OF WEST BENGAL

DEPARTMENT OF HEALTH AND FAMILY WELFARE

MUNICIPALITY BASIRHAT

BIRTH CERTIFICATE

(ISSUED UNDER SECTION 12/17 OF THE REGISTRATION OF BIRTHS & DEATHS ACT, 1969 AND RULE 8/13 OF THE WEST BENGAL
REGISTRATION OF BIRTHS & DEATHS RULES 2000.)

THIS IS TO CERTIFY THAT THE FOLLOWING INFORMATION HAS BEEN TAKEN FROM THE ORIGINAL RECORD OF BIRTH WHICH IS
THE REGISTER FOR MUNICIPALITY BASIRHAT OF BLOCK/MUNICIPALITY MUNICIPALITY BASIRHAT OF DISTRICT NORTH 24
PARGANAS OF STATE WEST BENGAL, INDIA.

NAME : AHMED BAJ GENDER : MALE

DATE OF BIRTH : 06/06/2022 PLACE OF BIRTH : ICHAMATI NURSING HOME,

MUNICIPALITY BASIRHAT, NORTH 24
PARGANAS, WEST BENGAL

NAME OF MOTHER : TASLIMA KHATUN NAME OF FATHER : GOLAM MOSTAFA BAJ

MOTHER'S IDENTITY PROOF : AADHAAR- FATHER'S IDENTITY PROOF : AADHAAR- 600141219055

409722949077

PRESENT ADDRESS OF MOTHER LOCALITY:- BADURIA,VILLAGE/TOWN:- BADURIA,MUNICIPALITY BADURIA MUNICIPALITY,DIST:- NORTH

AT THE TIME BIRTH OF THE 24 PARGANAS,WEST BENGAL-
CHILD :

PERMANENT ADDRESS OF LOCALITY:- BADURIA,VILLAGE/TOWN:- BADURIA,MUNICIPALITY BADURIA MUNICIPALITY,DIST:- NORTH

MOTHER : 24 PARGANAS,WEST BENGAL-

CERTIFICATE NO : B/2022/105605 DATE OF REGISTRATION : 16/06/2022

S-UHID : 03582879659957 REMARKS (IF ANY) :

DATE OF ISSUE : 21/06/2022 ISSUING AUTHORITY :

UPDATED ON : 2022-06-16 13:45:29

Signature Not Verified

Digitally Signed.
Name: SUBIR KUMAR DAS
Date: 24-Jun-2022 20:28:59

REGISTRAR (BIRTH & DEATH)

MUNICIPALITY BASIRHAT

"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 DOUCMENT FOR ALL OFFICIAL PURPOSES

"ENSURE REGISTRATION OF EVERY BIRTH AND DEATH "