सं.

1 उर देश सरकार प-5

NO. 1 GOVERNMENT OF UTTAR PRADESH FORM-5
चकसा एवं वाय वभाग
DEPARTMENT OF MEDICAL AND HEALTH
ाम पंचायत पपरया
GRAMA PANCHAYAT PIPRIYA

जम माण-प
BIRTH CERTIFICATE

(जम मृयु रिजकरण अधनयम, 1969 क धारा 12 / 17 तथा उर देश जम मृयु रिजकरण नयम, 2002 के नयम 8/13 के अंतगत जार कया
गया )
(ISSUED UNDER SECTION 12/17 OF THE REGISTRATION OF BIRTHS & DEATHS ACT, 1969 AND RULE 8/13 OF THE UTTAR PRADESH REGISTRATION
OF BIRTHS & DEATHS RULES 2002)

यह मािणत कया जाता है ननलिखत सूचना जम के मूल अभलेख से ल गई है जो क ाम पंचायत पपरया तहसील चकया िजला चंदौल राय/संघ
देश उर देश, भारत के रिजटर म उिलिखत है ।
THIS IS TO CERTIFY THAT THE FOLLOWING INFORMATION HAS BEEN TAKEN FROM THE ORIGINAL RECORD OF BIRTH WHICH IS THE REGISTER
FOR GRAMA PANCHAYAT PIPRIYA OF TAHSIL/BLOCK CHAKIA OF DISTRICT CHANDAULI OF STATE/UNION TERRITORY UTTAR PRADESH, INDIA.

नाम / NAME: IMRAN ALI लंग / SEX: पुरष / MALE

जम तथ / DATE OF BIRTH: जम थान/ PLACE OF BIRTH:

08-01-1999 PIPARIYA , PIPARIYA ,
EIGHTH-JANUARY-ONE THOUSAND NINE HUNDRED NINETY NINE PIPRIYA,CHAKIA, CHANDAULI,
UTTAR PRADESH, 232103

माता का नाम / NAME OF MOTHER: पता का नाम / NAME OF FATHER:

KHAIRUN NISHA MD MALLU ALI

आधार नंबर / MOTHER'S AADHAAR NO: आधार नंबर / FATHER'S AADHAAR NO:
XXXXXXXX8510
XXXXXXXX37

बचे के जम के समय माता-पता का पता / ADDRESS OF PARENTS AT THE TIME OF माता-पता के थायी पता/ PERMANENT ADDRESS OF PARENTS:
BIRTH OF THE CHILD:
PIPARIYA , PIPARIYA,
PIPARIYA , PIPRIYA, , CHAKIA, CHANDAULI, UTTAR PRADESH- 232103 PIPARIYA, PIPRIYA, CHAKIA, CHANDAULI,
UTTAR PRADESH- 232103

पंजीकरण संया / REGISTRATION NUMBER: पंजीकरण तारख / DATE OF REGISTRATION:

B-2023: 9-49777-000021 21-07-2023

टपणी / REMARKS (IF ANY):

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जार करने क तथ / DATE OF ISSUE: जार करने वाला ाधकार / ISSUING AUTHORITY :
21-07-2023
रिजार (जम एवं मृयु)
REGISTRAR (BIRTH & DEATH)
ाम पंचायत पपरया
GRAMA PANCHAYAT PIPRIYA

UPDATED ON :
21-07-2023 04:55:52

"THIS IS A COMPUTER GENERATED CERTIFICATE WHICH CONTAINS FACSIMILE SIGNATURE OF THE ISSUING AUTHORITY"
" 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".

" येक जम एवं मृयु का पंजीकरण सुनचत कर" / ENSURE REGISTRATION OF EVERY BIRTH AND DEATH "