Form-5

GOVERNMENT OF WEST BENGAL

DEPARTMENT OF HEALTH AND FAMILY WELFARE

GRAM PANCHAYAT ICHAPUR-II

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 GRAM PANCHAYAT ICHAPUR-II OF BLOCK/MUNICIPALITY GAIGHATA OF DISTRICT NORTH 24 PARGANAS OF
STATE WEST BENGAL, INDIA.

NAME : DIPANWITA KUNDU GENDER : FEMALE

DATE OF BIRTH : 31/04/2014 PLACE OF BIRTH : ,GAIGHATA, NORTH 24 PARGANAS,

ICHAPUR-II, KAYA, WEST BENGAL -
743249

NAME OF MOTHER : ROMA KUNDU ROY NAME OF FATHER : GOUTAM KUNDU

MOTHER'S IDENTITY PROOF : EPIC- XXXX/XX FATHER'S IDENTITY PROOF : -

PRESENT ADDRESS OF MOTHER STREET/LANE:- KAYA,LOCALITY:- GAIGHATA, VILLAGE/TOWN:- KAYA,GAIGHATA BLOCK,DIST:- NORTH
AT THE TIME BIRTH OF THE 24 PARGANAS,WEST BENGAL-743249
CHILD :

STREET/LANE:- SWAMIJI ROAD,LOCALITY:- BANIPUR, VILLAGE/TOWN:- BANUPUR,

PERMANENT ADDRESS OF BLOCK:- HABRA I, DIST:- NORTH 24 PARGANAS,WEST BENGAL-743233
MOTHER :

CERTIFICATE NO : B/2023/1293662 DATE OF REGISTRATION : 08/09/2014

OLD Reg. No- 388/14

S-UHID : 30630744373526 REMARKS (IF ANY) :

DATE OF ISSUE : 08/09/2014 UDIN : ----

UPDATED ON : 2023-11-09 17:21:30 ISSUING AUTHORITY :

Signature valid
Digitally Signed.
Name: DIPAK MONDAL
Date: 24-Nov-2023 17:35:42

SUB-REGISTRAR (BIRTH & DEATH)

GRAM PANCHAYAT ICHAPUR-II

"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