IN THE COURT OF THE EXECUTIVE MAGISTRATE/,TITILAGARH

In C.M.C No Of 2022

I Hara Pratap Dash aged about 27 year, S/O Late Bidhan Chandra Dash residence of At/ Po/Ps-Titilagarh
( Hatpada Pada) 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 Father 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 Father namely late Bidhan Chandra Dash S/O late Brundaban Dash died on
dt.10.06-2021 at Titilagarh.
3. That, in advert ant of law and ignorance, the petitioner & his family members could not registered the date
of death of his Father namely late Bidhan Chandra Dash S/O late Brundaban Dash before the
registration , Birth & Death i.e Titilagarh Municipality as required under registration of Birth and Death
Act.1969.
4. That, now the petitioner is in need of death certificate of her Father namely late Bidhan Chandra Dash
S/O late Brundaban Dash.
5. It is therefore, prayed that, your honor may be pleased to condone the delay for non-registration of the date
Father of the petitioner with in the period stipulated under the Act. And pass an order directing the
registrar, Birth and Death I.c Titilagarh Municipality to register the date of death of the Father of the
petitioner and issue a death certificate of petitioner’s Father namely late Bidhan Chandra Dash S/O late
Brundaban Dash For which act of kindness the petitioner as duty bound shall ever pray

Petitioner

Contd..P.2
 AFFIDAVIT

I Hara Pratap Dash aged about 27 year, S/O Late Bidhan Chandra Dash residence of At/ Po/Ps-Titilagarh
( Hatpada Pada) 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 I do hereby declare that the content of this affidavit are
true to the best of my knowledge and belief. Hence I
explained the contents of this affidavit to the
put my Signature on this the December 24 2022.
deponents and they admitted it to be true and
correct. I identify the deponents.

Advocate Deponent