हिरयाणा सरकार

सं . 1 GOVERNMENT OF HARYANA प-5

No. 1 वाय से वाएं िवभाग FORM-5
DEPARTMENT OF HEALTH SERVICES
MUNICIPAL CORPORATION GURUGRAM
नगर िनगम गु ग ाम

जम माण-प
BIRTH CERTIFICATE

(जम मृ यु रिजट ीकरण अिधिनयम, 1969 की धारा 12 / 17 तथा हिरयाणा जम मृ यु रिजट ीकरण िनयम, 2002 के िनयम 8/13 के अं तगत जारी िकया गया )
(ISSUED UNDER SECTION 12/17 OF THE REGISTRATION OF BIRTHS & DEATHS ACT, 1969 AND RULE 8/13 OF THE HARYANA
REGISTRATION OF BIRTHS & DEATHS RULES 2002.)

यह मािणत िकया जाता है िननिलिखत सूचना जम के मूल अिभले ख से ली गई है जो िक ...... तहसील ...... िजला ...... राय/सं घ दे श हिरयाणा,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 ....... OF TAHSIL/BLOCK ...... OF DISTRICT ....... OF STATE/UNION TERRITORY HARYANA, INDIA.

नाम / NAME : KAMLA िलं ग / SEX : FEMALE

जम ितिथ / DATE OF BIRTH:

01-07-1959 जम थान / PLACE OF BIRTH :
FIRST-JULY-NINETEEN FIFTY NINE GURUGRAM

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

KISHANDEI MOHAN LAL

आधार सं या / MOTHERS AADHAAR NO : आधार सं या / FATHERS AADHAAR NO:

XXXXXXXX XXXXXXXX

बचे के जम के समय माता-िपता का पता / ADDRESS OF PARENTS AT THE TIME OF माता-िपता का थाई पता / PERMANENT ADDRESS OF PARENTS:
BIRTH OF THE CHILD : KANAHI(73), GURGAON, GURAON, HARAYANA-122003
KANAHI(73), GURGAON,GURAON, HARAYANA-122003

पं जीकरण सं या / REGISTRATION NUMBER: पं जीकरण तारीख / DATE OF REGISTRATION:

B-2023: 9-90347-008584 29-06-2023

िटपणी / REMARKS (IF ANY):

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जारी करने का ितिथ / DATE OF ISSUE : जारी करने वाला ािधकारी / ISSUING AUTHORITY :
05-07-2023
रिजटार (जम एवं मृ यु )
REGISTRAR (BIRTH & DEATH)
नगर िनगम गु ग ाम
MUNICIPAL CORPORATION GURUGRAM

UPDATED ON :
05-07-2023 12:44:16

"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".

" ये क जम एवं मृ यु का पं जीकरण सु िनिचत कर "/ ENSURE REGISTRATION OF EVERY BIRTH AND DEATH "