Form - 5

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GOVERNMENT OF KARNATAKA

Chief Registrar of Births and Deaths

(t8.5.Ñef Nosb, 19690 12/17R¢o edo Yre t.o.b.ÑAt. Jabsbriss,

1999d Nodbab 8/13d aeoi tetced)
BIRTH CERTIFICATE
(Issued Under Section 12/17 of the RBDAct, 1969 and Rule 8/13 of the KRBD Rules, 1999)

This is to certify that the following information has been taken from the original record of birth which is the register for
|Chintamani (CMC) (village/town) of Chintamani taluk of Chikkaballapura district of Karnataka State
Y NIHANYA 2) Oort
Name Y NIHANYA Sex Female
3) Baeo DÔeaD 06/08/2022 4) Bsdaad g General Hospital, Chintamani
|Date of Birth Place of Birth (CMC),Chintamani
,Chikkaballapura, Karnataka
6) doda t d
Name of Mother POOJA M Name of Father YAALAM ANIL KUMAR

8) dodsDDabd aDabo v
e3osead Jid, sosoad, ds2vd, Bv•FB8 563125 Amadagur, Amadagur, Anantapur, Andhra Pradesh
515556
Address of parents at the time of birth of the child: Permanent address of parents:
-Chintamani (CMC),Chintamani ,Chikkaballapura,Karnataka 563125 -, Amadagur,Amadagur,Anantapur,Andhra Pradesh 515556
9) ioeodd doa 803231/H/BI2022/002467 10) toeODdi Obea) 11/08/2022
Registration No.: Date of Registration:
) seaiDj0Pgd g) CHIKKABALLAPURA D- 12) batoedtab BDO8 27/12/2022
Remarks(if any) Date of Approval

|Digitally signed certificate, manual signature is not required. Address of the issuing authority Medical Officer
General Hospital, Chintamani Taluk, Chikkaballapura Distr t

Date of Issue 27/12/2022

"Ensure registration of every birth and death"

doe: wdd detodcobd, https://eianma.karnataka.gov.in d, drDABe,
Note: Verify the Birth registration at https://ejanma.karnataka.gov.In