(English Version) FORM NO-5 ISSUE NO : 50/2026 a GOVERNMENT OF ODISHA DEPARTMENT OF HEALTH AND FAMILY WELFARE BENTAKAR 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 BENTAKAR CHC of Tahasil CUTTACK SADAR of District. CUTTACK of State ODISHA NAME: PARIMITA MOHAPATRA, DATE OF BIRTH (08/10/2022 NAME OF MOTHER: KALPANA MOHAPATRA, MOTHER'S AADHAR NO: wom ADDRESS OF PARENT AT THE TIME OF CHILD BIRTH:DARADAGRAM, SIDHESWARPUR, BIRIDI, JAGATSINGHPUR, ODISHA, INDIA, 754100 REGISTRATION Nt 5367/2022, UBRN NO: 21RB3S0-0043-000567-2022 Signature ‘SEX: FEMALE PLACE OF BIRTH JEEVAN JYOTI NURSING HOME , KISHAN NAGAR , ‘CUTTACK: NAME OF FATHER: ‘SAMAR BALLABHA MOHAPATRA, FATHER'S AADHAR NO: Eavieeegyse PERMANENT ADDRESS OF PARENTS: DARADAGRAM, SIOHESWARPUR, BIRIDI, JAGATSINGHPUR, ODISHA, INDIA, 754100 REGISTRATION DATE: 1710/2022 DATE OF ISSUE: s1ioti2024 Dr Basanta Kumar Sahoo Issuing Authority Registrar, Births & Deaths BENTAKAR CHC THIS Is A COMPUTER GENERATED CERTIFICATE WHICH CONTAINS FACSIMILE SIGNATURE OF THE ISSUING AUTHORITY. Wis 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:/iwww.birthdeath.odisha.gov.in Tampering of this certificate will attract a a