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waa 5
No. Form-5
WOR
State GOVERNMENT OF
Emblem | ~~ _ATATT....-
(oaerea ot we aT sextaPror oF)
DEPARTMENT OF J
(Ramo of iocal bod issuing cerca)
OA FATA
BIRTH CERTIFICATE
carry eforeheren aifPan, 1960 wh aTeT 1217 TaN. rH a ePRINTT Pa,
Cer aH)
& Pram 9/13 & oferta are fen
Giehe Pre a ages fg or pr ah
(issued under Section 12/17 of the Registration of Births and Deaths Act, 1969 and Rule 8/13
ofthe Registration of Births and Deaths Rules.
(Name of Sat) (Wear of ntiyng the vviod res)
ae vee Fa a PRIN ET OP a Se a REPT
sexta
fore ~ XT ~ & efereey F afealtad
a
“This isto cert that the following information has been taken from the original record of birth
wich is the revjister or (local areafocal body) tans /
block of District of Statefinion teritory
AIFU/Name:
‘fc#/Sex.
‘a FARR, Date of Bith
“OFF YeIA/Place of bith...
“IRI 1 -T/Name of Mother.
ATAT FT FATEST F® JID No of Mother
{ite @FATA/Name of Father
Prat FT Fares A/D No of Father a
aged crea eee en fen eT GAT sare fet aor een ery
Address of parents at the time of birth of the child Permanent address of parents:
‘tofleeor teAI/Registration No .... ister fts|Date of Registration...
fount Remarks (if any)..... ost
ward) ea a Ay Date of issve: sfeor8 & BeTE/Signature ofthe issuing authority
freon WT TT) Address ofthe issuing authority
‘HIE/Seal
volkp oy Yan yey STiviteeorgfatead Hy) “Ensure registration of every birth and death
