Form-5

GOVERNMENT OF WEST BENGAL

DEPARTMENT OF HEALTH AND FAMILY WELFARE

SUB DIVISIONAL HOSPITAL JANGIPUR

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 SUB DIVISIONAL HOSPITAL JANGIPUR OF BLOCK/MUNICIPALITY MUNICIPALITY JANGIPUR OF DISTRICT
MURSHIDABAD OF STATE WEST BENGAL, INDIA.

NAME : KEYA MANDAL GENDER : FEMALE

DATE OF BIRTH : 25/09/2023 PLACE OF BIRTH : SUB DIVISIONAL HOSPITAL JANGIPUR,

MUNICIPALITY JANGIPUR,
MURSHIDABAD, WEST BENGAL

NAME OF MOTHER : SOMA DAS MANDAL NAME OF FATHER : PARIMUL MANDAL

MOTHER'S IDENTITY PROOF : AADHAAR- FATHER'S IDENTITY PROOF : AADHAAR- XXXXXXXX4644

XXXXXXXX8573

PRESENT ADDRESS OF MOTHER STREET/LANE:- BORDERPARA,LOCALITY:- BORDERPARA,VILLAGE/TOWN:- PASCHIM CHAR

AT THE TIME BIRTH OF THE MAJHARDIAR,RANINAGAR - II BLOCK,DIST:- MURSHIDABAD,WEST BENGAL-742308
CHILD :

PERMANENT ADDRESS OF STREET/LANE:- BORDERPARA,LOCALITY:- BORDERPARA,VILLAGE/TOWN:- PASCHIM CHAR

MOTHER : MAJHARDIAR,RANINAGAR - II BLOCK,DIST:- MURSHIDABAD,WEST BENGAL-742308

CERTIFICATE NO : B/2023/1115979 DATE OF REGISTRATION : 04/10/2023

S-UHID : 41582913832467 REMARKS (IF ANY) :

DATE OF ISSUE : 04/10/2023 ISSUING AUTHORITY :

UPDATED ON : 2023-10-04 15:05:51

Signature Not Verified

Digitally Signed.
Name: Prodip Chakrobarty
Date: 04-Oct-2023 16:45:09

REGISTRAR (BIRTH & DEATH)

SUB DIVISIONAL HOSPITAL JANGIPUR

"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 "