IN THE COURT OF THE EXECUTIVE MAGISTRATE/,TITILAGARH

In C.M.C No Of 2022

I Sheshadeb Majhi aged about 48 year, S/O Kundru Majhi residence of At,Kamarlaga Po-Ambapali Ps-
saintala Dist-Bolangir (Odisha) do hereby solemnly affirm and state as follow:-

………… Petitioner

PETITION U/S.13(3) OF THE REGISTRATION OF DEATH ACT.1969

The petitioner named above begs to state as follows:

1. That, the petitioner’s late Grandfather was residing at the above mentioned address at the time of his death
within the jurisdiction of this Hon’ble Court.
2. That, the petitioner’s Grandfather namely late Khasu Majhi S/O late sadia majhi died on dt.07.06.1992 at
Kamarlaga .
3. That, in advert ant of law and ignorance, the petitioner & his family members could not registered the date
of death of his Grandfather namely late Khasu Majhi S/O late sadia majhi before the registration, Birth &
Death i.e. C.H.C, Saintala as required under registration of Birth and Death Act.1969.
4. That, now the petitioner is in need of death certificate of his late Grandfather namely late Khasu Majhi S/O
late sadia majhi.
5. It is therefore, prayed that, your honor may be pleased to condone the delay for non-registration of the date
Grandfather of the petitioner with in the period stipulated under the Act. And pass an order directing the
registrar, Birth and Death I.c C.H.C Saintala to register the date of death of the Grandfather of the
petitioner and issue a death certificate of petitioner’s Grandfather namely late Khasu Majhi S/O late sadia
majhi For which act of kindness the petitioner as duty bound shall ever pray

Petitioner

Contd..P.2
 AFFIDAVIT

I Sheshadeb Majhi aged about 48 year, S/O Kundru Majhi residence of At,Kamarlaga Po-Ambapali Ps-
saintala Dist-Bolangir (Odisha) do hereby solemnly affirm and state as follow:-

1. That, I am the petitioner in the above mentioned case.

2. That, the facts stated in the petition above are true to the best of my knowledge, belief and information.

Hence this affidavit

Deponent

Drafted & got typed by me. Read over

explained the contents of this affidavit to the I do hereby declare that the content of this affidavit are
deponents and they admitted it to be true and true to the best of my knowledge and belief. Hence I
correct. I identify the deponents. put my Signature on this the March 28, 2022

Advocate Deponent