yuT-6

ORNMEA
GOVERNMENT OF ¯ITAR PRADESH FORM-6

DEPARTMENT OF MEDICAL AND HEALTHH

COMMUNI0Y HEALTIICENTRE SARIY¢URF MUSAFIRKIIANA

DEATH CERTIFICATE

fs fargH, 2002 # feruA 8/13 GTfT T4T)

RULE 8/13 OF THE UTTAR PRADESH REGISTRATION OF
(ISSUED æNDER SECTION 12/17 OF THE REGISTRATION OF BIRTHS & DEATH`ACT, 1969 AND
BIRTHS& DEATHSRULES 2002.)

THIS IS TO CERTIFY THAT THE FOLLOWING INFORMATION HAS BEEN TAKEN FROM THE ORIGINAL RECORD OF DEATH WHICH IS THE REGISTER FOR
CENTRE SARIYA URF MUSAFIRKHANA OF TAHSILUBLOCK MUSAFIRKHANA OF DISTRICT AMETHI OF STATE/UNION TERRITORY
COMMUNITY HEALTH
UTTAR PRADESH, INDIA.

H1 A/NAME OF DECEASED : RUPESH KUMAR SRIVASTAVA ft / SEX: yRT| MALE

STTT e r / AADHAAR NO.:
XXXXXXXX9390
HY AT FYTT | PLACEOF DEATH:
Hey Tat / DATE OF DEATH: CHC SARIYAURF MUSAFIRKHANA
i-ß2-2024
ELEVENTH-FEBRUARY-TWO THOUSAND TWENTY FOUR gfd /yt T H / NAMEOF HUSBAND/ WIFE:
JYOTIKA SRIVASTAVA
HHG 34 /AGE OF DECEASED: 3ATETTT T/ HUSBAND/WIFE AADHAAR NO. :
51 YEARS XXXXXXXX1631
fodT FT H| NAME OF FATHER:
HIdT ol H / NAME OF MOTHER: VINAY PRAKASH VERMA
SHAKUNTALA VERMA
3ATTT T FATHER'S AADHAAR NO, :
3TTITT 7qT / MOTHER'S AADHAAR NO,

TIME OF DEATH Hdo aT TYI yT PERMANENT ADDRESS OF DECEASED:

He4 HHY HA# AI Yal /ADDRESS OF THE DECEASED AT THE
50/B RAIENDRA NAGAR JAIL ROAD,
SARIYA URF MUSAFIRKHANA, MUSAFIRKHANA, AMETHI, SULTANPUR, SULTANPUR, SULTANPUR,
UTTAR PRADESH
UTTAR PRADESH

s U TGT | REGISTRATION NO: dsitthU arrs/ DATE OF REGISTRATION:

D-2024:9-60730-000002 23-02-2024

fuv /REMARKS (IF ANY):

sIâ â faf/ DATE OF ISSUE: HIt KÀ atel TfercaTÆT / ISSUING AUTHORITY

23-02-2024
REGISTRAR (BIRTH &
DEATH)
cOMMUNITY HEALTH CENTRE SARIYÀ URF MUSAFIRKHANA

UPDATED ON:
23-02-2024 11:01:00

"THIS IS ACOMPUTER 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.
H qH OT YtG RI / ENSURE REGISTRATION OF EVERY BIRTIH AND DEATH"