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 : SAYANTIKA KARMAKAR GENDER : FEMALE

DATE OF BIRTH : 04/06/2010 PLACE OF BIRTH : CHITTARANJAN SEBA SADAN

NAME OF MOTHER : PAMPA KARMAKAR NAME OF FATHER : SHIB SANKAR KARMAKAR

MOTHER'S IDENTITY PROOF : NOT AVAILABLE. FATHER'S IDENTITY PROOF : -

IDENTITY CERTIFIED BY
REGISTRAR/SUB-
REGISTRAR-

PRESENT ADDRESS OF MOTHER 52,TARATALA ROAD,BRACE BRIDGE,PS-TARATALA,CIRCUS AVENUE, KOLKATA-700088

AT THE TIME BIRTH OF THE CHILD
:

PERMANENT ADDRESS OF 52,TARATALA ROAD,BRACE BRIDGE,PS-TARATALA,CIRCUS AVENUE, KOLKATA-700088

MOTHER :

CERTIFICATE NO : I/06/2010/18654 DATE OF REGISTRATION : 02/07/2010

S-UHID : REMARKS (IF ANY) :

DATE OF ISSUE : 02/07/2010 ISSUING AUTHORITY :

UPDATED ON : 2010-07-02 12:01:46

;;;'/.......
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 "