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 मौल तालुका मनयार
GRAMA PANCHAYAT MISHRAULI TALUKA MANIYAR

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 मौल तालुका मनयार तहसील बांसडीह िजला बलया
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 MISHRAULI TALUKA MANIYAR OF TAHSIL/BLOCK BANSDIH OF DISTRICT BALLIA OF STATE/UNION TERRITORY UTTAR PRADESH,
INDIA.

नाम / NAME: NAITIK GAUTAM लंग / SEX: पुरष / MALE

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

11-04-2018
ELEVENTH-APRIL-TWO THOUSAND EIGHTEEN MISHRAULI TALUKA MANIYAR,BANSDIH, BALLIA,
UTTAR PRADESH

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

ANITA NIKHILESH

आधार नंबर / MOTHER'S AADHAAR NO: आधार नंबर / FATHER'S AADHAAR NO:
XXXXXXXX4156
XXXXXXXX2487

बचे के जम के समय माता-पता का पता / ADDRESS OF PARENTS AT THE TIME माता-पता के थायी पता/ PERMANENT ADDRESS OF PARENTS:
OF BIRTH OF THE CHILD:
VILL - ISMAILPUR BARAHATI, VILL - ISMAILPUR BARAHATI,
POST - KATAULI KALAN, ISMAILPUR BARHATI, , LALGANJ, AZAMGARH, UTTAR POST - KATAULI KALAN, ISMAILPUR BARHATI, LALGANJ,
PRADESH- 276202 AZAMGARH,
UTTAR PRADESH- 276202

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

B-2021: 9-45858-000418 07-12-2021

टपणी / REMARKS (IF ANY):

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जार करने क तथ / DATE OF ISSUE: जार करने वाला ाधकार / ISSUING AUTHORITY :
07-12-2021
रिजार (जम एवं मृयु)
REGISTRAR (BIRTH & DEATH)
ाम पंचायत मौल तालुका मनयार
GRAMA PANCHAYAT MISHRAULI TALUKA MANIYAR

UPDATED ON :
07-12-2021 10:10:28

"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 "