(English Version) FORM NO-5

ISSUE NO : 352/2024

GOVERNMENT OF ODISHA

DEPARTMENT OF HEALTH AND FAMILY WELFARE

BANARPAL CHC

CERTIFICATE OF BIRTH
Issued under Section 12/17 of the Registration of Births and Deaths Act, 1969 and 8/13 Rule of the Odisha
Registration of Births and Deaths, Rule 2001
This is to certify that following information has been taken from the original records of birth which is in the
register for BANARPAL CHC of Tahasil BANARPAL
of District ANGUL of State ODISHA

NAME: PRIYANSHI SAMAL SEX: FEMALE

DATE OF BIRTH: PLACE OF BIRTH:

08/07/2023 SAROJINI HEALTH CARE , BANARPAL , ANGUL

NAME OF MOTHER: NAME OF FATHER:

TULASI SAMAL PRADEEP SAMAL

MOTHER'S AADHAR NO: FATHER'S AADHAR NO:

********9413 ********7833

ADDRESS OF PARENT AT THE TIME OF CHILD PERMANENT ADDRESS OF PARENTS:

BIRTH:DUDURKOTE, BALIMI, ANGUL, ODISHA, INDIA DUDURKOTE, BALIMI, ANGUL, ODISHA, INDIA

REGISTRATION NO: REGISTRATION DATE:

929/2023 27/07/2023

UBRN NO: DATE OF ISSUE:

21RB344-0022-000929-2023 17/02/2024

Signature Not Verified Dr Sankarsan Gan

Digitally Signed. Issuing Authority
Name: SANKARSAN GAN
Date: 17-Feb-2024 11:18:34 Registrar, Births & Deaths
Reason: Birth Certificate
Location: BANARPAL BANARPAL CHC

THIS IS A COMPUTER GENERATED CERTIFICATE WHICH CONTAINS FACSIMILE SIGNATURE OF THE ISSUING AUTHORITY.
It is a digitally signed electronically generated certificate and therefore needs no ink-signed signature,stamp or seal. This certificate is
issued as per section 4,5 & 6 of information technology Act 2000 and it's subsequent amendments in 2008.For any query or
verification, please visit https://www.birthdeath.odisha.gov.in Tampering of this certificate will attract
penal action.