Form-6

GOVERNMENT OF WEST BENGAL

DEPARTMENT OF HEALTH AND FAMILY WELFARE

SUB DIVISIONAL HOSPITAL SERAMPORE (WALSH)

DEATH CERTIFICATE

(ISSUED UNDER SECTION 12/17 OF THE REGISTRATION OF BIRTHS & DEATHS ACT, 1969 AND RULE 8/13 OF THE WEST BENGAL
REGISTRATION OF BIRTHS & DEATHS RULES 2000.)

THIS IS TO CERTIFY THAT THE FOLLOWING INFORMATION HAS BEEN TAKEN FROM THE ORIGINAL RECORD OF DEATH WHICH IS
THE REGISTER FOR SUB DIVISIONAL HOSPITAL SERAMPORE (WALSH) OF BLOCK/MUNICIPALITY MUNICIPALITY SERAMPORE OF
DISTRICT HOOGHLY OF STATE WEST BENGAL, INDIA.

NAME OF DECEASED : KAUSIK SEX : MALE

MUKHOPADHYAY

DATE OF DEATH : 09/10/2023 PLACE OF DEATH : SUB DIVISIONAL HOSPITAL SERAMPORE

(WALSH), MUNICIPALITY SERAMPORE,
HOOGHLY, WEST BENGAL

AGE OF DECEASED : 49 YEARS NAME OF SPOUSE :

SPOUSE IDENTITY PROOF. : -

NAME OF MOTHER : NAME OF FATHER : MADAN MOHAN MUKHOPADHYAY

MOTHER'S IDENTITY PROOF : - FATHER'S IDENTITY PROOF : -

ADDRESS OF THE DECEASED AT BLDG.NO & NAME:- 1ST FLOOR , FLAT 1B,HOUSENO:- 13/B,STREET/LANE:- BARA BAGAN
THE TIME OF DEATH : LANE,LOCALITY:-MALLICKPARA, VILLAGE/TOWN:- SERAMPORE,MUNICIPALITY
SERAMPORE,DIST:- HOOGHLY,WEST BENGAL-712203

PERMANENT ADDRESS OF BLDG.NO & NAME:- 1ST FLOOR , FLAT 1B,HOUSENO:-13/B,STREET/LANE:-BARA BAGAN
DECEASED : LANE,LOCALITY:-MALLICKPARA, VILLAGE/TOWN:- SERAMPORE, MUNICIPALITY
SERAMPORE,DIST:- HOOGHLY,WEST BENGAL-712203

CERTIFICATE NO : D/2023/0532807 DATE OF REGISTRATION : 17/10/2023

REMARKS (IF ANY) :

DATE OF ISSUE : 17/10/2023 ISSUING AUTHORITY :

UPDATED ON : 2023-10-17 16:26:47

Signature Not Verified

Digitally Signed.
Name: BIJON BEHARI SAHA
Date: 17-Oct-2023 18:04:56

SUB-REGISTRAR (BIRTH & DEATH)

SUB DIVISIONAL HOSPITAL
SERAMPORE (WALSH)

"THIS IS A COMPUTER GENERATED CERTIFICATE."

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

"ENSURE REGISTRATION OF EVERY BIRTH AND DEATH "