सं.

1
No. 1
उर देश सरकार प-6
GOVERNMENT OF UTTAR PRADESH FORM-6
चकसा एवं वाय वभाग
DEPARTMENT OF MEDICAL AND HEALTH
ाम पंचायत खजुरहा
GRAMA PANCHAYAT KHAJURIHA

मृयु माण-प
DEATH 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 मृयु के मूल अभलेख से ल गई है जो क ाम पंचायत खजुरहा तहसील सरौल गौसपुर िजला बाराबंक 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 DEATH WHICH IS THE REGISTER FOR GRAMA
PANCHAYAT KHAJURIHA OF TAHSIL/BLOCK SIRAULI GAUSPUR OF DISTRICT BARA BANKI OF STATE/UNION TERRITORY UTTAR PRADESH, INDIA.

मृतक का नाम / NAME OF DECEASED : ASHVINI KUMAR लंग / SEX: पुरष / MALE

आधार नंबर / AADHAAR NO.:

XXXXXXXX0918

मृयु क तथ / DATE OF DEATH: मृयु का थान / PLACE OF DEATH:

21-04-2023 KHAJURIA, SIRAULI GAUSPUR, BARA BANKI, UTTAR PRADESH.
TWENTY-FIRST-APRIL-TWO THOUSAND TWENTY THREE
पत / पी का नाम / NAME OF HUSBAND / WIFE:

मृतक क उ / AGE OF DECEASED:

43 YEARS आधार नंबर / HUSBAND/WIFE AADHAAR NO. :

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

MAHADEV PRASAD

आधार नंबर / MOTHER'S AADHAAR NO. :

--- आधार नंबर / FATHER'S AADHAAR NO. :
---

मृयु के समय मृतक का पता / ADDRESS OF THE DECEASED AT THE TIME OF DEATH : मृतक का थायी पता / PERMANENT ADDRESS OF DECEASED :

KHAJURIA, SIRAULI GAUSPUR, BARA BANKI, KHAJURIA, SIRAULI GAUSPUR, BARA BANKI,
UTTAR PRADESH UTTAR PRADESH

पंजीकरण संया / REGISTRATION NO: पंजीकरण तारख / DATE OF REGISTRATION:

D-2023: 9-29595-000005 27-04-2023

टपणी / REMARKS (IF ANY):

---

जार करने क तथ / DATE OF ISSUE: जार करने वाला ाधकार / ISSUING AUTHORITY
02-01-2024
रिजार (जम एवं मृयु)
REGISTRAR (BIRTH & DEATH)
GRAMA PANCHAYAT KHAJURIHA
ाम पंचायत खजुरहा

UPDATED ON :
2023-04-27 17:45:22

"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 DOUCMENT FOR ALL OFFICIAL PURPOSES.

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