Form-5

GOVERNMENT OF WEST BENGAL

DEPARTMENT OF HEALTH AND FAMILY WELFARE

KOLKATA MUNICIPAL CORPORATION

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 KOLKATA MUNICIPAL CORPORATION OF BLOCK/MUNICIPALITY KOLKATA MUNICIPAL CORPORATION OF
DISTRICT KOLKATA OF STATE WEST BENGAL, INDIA.

NAME : RAJARSHI MALLIK GENDER : MALE

DATE OF BIRTH : 12/04/1983 PLACE OF BIRTH : WOODLANDS NURSING HOME,CAL-27 ,

WARD HEALTH UNIT 24

NAME OF MOTHER : ANITA MALLIK NAME OF FATHER : DR. DEBABRATA MALLIK

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

XXXXXXXX1440

PRESENT ADDRESS OF MOTHER 9/3/1,BEDIA PARA LANE,DUMDUM,CAL-77

AT THE TIME BIRTH OF THE
CHILD :

PERMANENT ADDRESS OF 9/3/1,BEDIA PARA LANE,DUMDUM,CAL-77

MOTHER :

CERTIFICATE NO : I/04/1983/11396 DATE OF REGISTRATION : 26/10/1983

S-UHID : REMARKS (IF ANY) :

DATE OF ISSUE : 15/09/2022 ISSUING AUTHORITY :

UPDATED ON : 2022-09-15 14:18:43

Signature Not Verified

Digitally Signed.
Name: PURABI PANDEY
Date: 15-Sep-2022 14:48:20

SUB-REGISTRAR (BIRTH & DEATH)

KOLKATA MUNICIPAL CORPORATION

"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 DOCUMENT FOR ALL OFFICIAL PURPOSES

"ENSURE REGISTRATION OF EVERY BIRTH AND DEATH "