af or Department of Health and Family Welfare / fra wd ufsers afswre erat Delayed Registration of Birth | ou Hsdifede Gt Se sfrA’as (Information form no. 1) For Office Use Only _ a - Apgiication Number / it Sao None occ Tad raw sts © | Part— 1 Personal Details | feverstas 2a f a "Personal Data of Applicant! Siar Sar (hese dems ae ofthe person who fs aplyng ot beh! of bensicien of bith ceriieae Aes ar On few 3S em retiite Crest 8 see Sete fee a) Tags 7455904 —| : \IPo- DADA DIST HosmarPuR “Pas HARIOR —— 72. Sub DistieyTehsi i j hou nag = Droq oe a ‘adress sarve as permanent address Note: Th soso wil be procezned bye Dsinct Maysralecrrespondrg to Preset Corespondente Address of Appicant and th appicant ‘ust be residing at this adress for moro thon 6 month. 15. Village (in case of “SAME AODREso _ = nee : Vi Y 22 Applicant's Relation wath Benoficary / | hae at hes iheveasesens one Page 1 of7 Last Rev: Jul 2019,38 (@) Access of pace oben (ony ncasoer [HERG AT PO — DADA DIST HOSHARPUR wranaie RS od ret 3 AS PheryT aS A RTE RET RE aaa 35a iar ad BF eT SPNTOKH LAL Biya vpo- aod (os Fa aA Tw pist roswareiR PIX Pwd 70 Non avaitycarcan UAC) data] a QRS TARAS GES 1 sno | Conte no/setite tom | Catealte nouns /#ROE@ GR” | Fromaate/BSch | Toaue/ eb + _[BR/NAC/oo6S541781 | 5-09-2084 JOF-07-Ro04 [03-07-2004 | 2 208 Informant address rears Oe we eras 3 i us i | | 41. Block office (ofice to which application to be sent Vera wees are dy WIL SURGEN OFFICE HeSHIARPUR | Part 2 List of Required Documents /gStenares Ut. Please tck (\) the document attached / row mai Sat erste 6 far () 48 | Name of Document EASA =a = ‘Late registration of birth — within one year/ Went Gs otimredan - fia ms ees 7. | 10am Residence Proof et Ropieant mee | Aika acai by age & Nsiay Pic = | 3. —| Nan Arca Cas Pang i Hs Year aT a ore = anes | | & | Proor orbimn ike naspal nursing home report or mmuization card 6ic QMardaloy # Date o Bich Mandatory / gt Win one year) LL ‘5. | Witnesses of two credible persons ike Sarpancty Panch’ Muricipal Councilor’ MUAY MP or Gazetted Ottcer under statorle 1 = ‘te registration ofthe one yearn @ By efimetao - Bare Care - ‘D eum Residence Proof of Aepicant endatory aleneos "Sal Sacra a po Pesarbed Toma i 7 Vandi EE Last Rev: Jul 2019 Page 3 of 7reasamaeee PANU BALA =i ae ere Sara wal | yr a ee oe 7 Cana tat™ Tete a Cl Female tua Cl teoungondae/ eae is Father wigon / Rise ma 0 Ski Aas nhs Eos Bi Date ol bith OMB” i Age bate stb nat ONT 31. Maia sass / OOS HEH * 08-07-2004 | gaaemonat actos an Broce Waimared Marie’ 0 Th Weow ET Sopanted 22, Spouse Name / Been € 3 (only im case of beneficiary is Martied or Widowed ) 38, Age of mother atthe ime of child tinh 748 SHR a es” Qu yeAR 4. Order No. of tinh jE Sea sora fe ers © Bi Adiress ol parses aie ine or wen YY PO -DADA DIST HosmMARPUR tePunpbt = Rosmd grag aH hw Prmew ‘35. Permanent Address OF Parents! Ha" fia = etter 37.Reason torlate enty /82 Ned saree was" Ty ang Rigr Shea aI nEaEE> “VY PO- OADA DIST HOSHIARPUR nema Rom} germ 37 Pi, Pays | Si Place of Birth details l@) Regisralion Region! ahmietae Bae 7 Real TT iter 2 @)Reguiaton Dect atinedus tag” [MOSHIAROUR — | 382 Retiton Tema aieoas jacana 33 (@) Place of bith FH RS * CY GontRespial Ty Piva Fwiad———R}“Flome Oo Os | ee ROME = separ war BS Last Rev: Jul 2019 Page 2 of 73] Witnesses offie ceaie parsons lice Sarpanehy Pach Mnicpal Counc MIA WF or Gaztiod andy Taga ‘Oficer understate re 14 (Mandatory i Date of Death ater ane year) we °E_| Nen Availabilty Caiticale of3 years search partaing othe year of ocsurence of even, prov o yaar of occurence and ater te year of occurence Mandatory FES (incase the event occured incurent year as of date ot application. hen i site o after the year of ee ‘ocaurance, the record to be searched for prior to prior year of occurence of event | a Proofof bith Iie Rospial nursing home repor in case of htiuional AS is Mancelory / #gat '. Copy of school certfeste or passport or enmunization cant or diving foense or andar cant or voter card in case of domicitery bith or any other proof which shows date ark ploce of rth. Le ‘| Copy afin school cortcate or pessport or volo card orang Woanba o wad card = ‘brothersissters of child where D.O.B and Father name of stings & metioned (Incase of slings) Mandatory / I Rito tae awe a8 Tf Qudas ns ws Set ene Re yoo Tat Teed we fre wows wore O18 Reged ertorad ford | Ande g dat sq ay Baas Ra ere RA ad yor YS AES IAI Rage ngre Bre a vates dea / Sesh 1 wid gs Fe eS BN Sos HRS Ia Sa AeA] | solemnly declare that the information provided as above and in attached documents is correct as per my bellef and 1no information has been hidden in this. | em aware of the fact that it any of the information provided by me is proved incorrectiwrong then | can be punished in the court of law as per the provisions in the relevant Acts/rulesinolifications and ‘depending upon this wrong information, all the benefits provided by government to me shall also be stopped immediately, SefeyDeted: Nesllees Singh fierosesDecarant (Ctizen's Signature | Thumb Impression Last Rev: Jul 2019 Page 4 of 7warts as zt RS wi a5 nie a gts ot ar “ wee SE A, By wr. es = CK BR wr a Rater at Gamer a a Sows Ofer wt 1 A Gua fee fers ge a/ uae wot ie 3 seth Ber s wot opera: wet Dreetaen mag Sethe eres Rous (Distt. Hoshiarpur 5 Oude wag fe Serer s aT ators, entta ot nts ten fis we does ot 1 7 Ht. Sed Sr agree 8 & An fis & Oe Ger Owe Ten FE wot Hh . te fen 2 vatlact w Ho AD fig fe fet OF-0 Tool. § dow wt w te wr duet wat He @ wu ERs AB IS fers Tao urfks oS sadta dpe J neo ee Sefee Ms TF we IT sta, RMIT dno % Th Que fat Giors @ net weet Oet ma aT el wa fil WH AES Wdl As & feom ot widt ast we fe Gutlas wees fer au er fis et Gar erga 3 noe fee erop Ut ARTSY ak ab wih Bake THY C ee La aie a rs ABR Siow Sails A Fo Rs) to--20ah SAS TEE SR WOR as WS de | V.P.0. Dada Distt. HoshiarpurDocument Sr. No: ES11048217 __sistration No: DRVES/210028480657 ura Has! Government of Punjab fras 3 ufees se fess / Health and Family Welfare Department te ofimreers Het 3 vs, Ure Chief Registrar (Birth & Death), Punjab Hz ernadifederDeath Certificate sits DPH-359 Fens For -7 fe aradts Fe dh oe fet geo wre ts eres fed ot add rad fe we chews, TON SHS, sea UME, Teer ses sts giweus fay girraus Une, 2s 2021 2 SAeS Rev eaH DI ‘certify that following information has been taken from the original death record which is registered in he death register of ‘egistrar. Birth & Death Block PHC Harta Badia , Tehsil Hoshiarpur, District Hoshiarpur of Punjab State for the yoar 2021 IName of Deceased: Sate EH / NARAIN DAS sa! Male =a / Spouse's udtg 2€/ PRITU DEVI ar iFathers Name: PRT SH / BAVARAM. 2x Mother'sName: — @eSt/ JUWALI S fit (Date Of Death: 10/11/2021 Se ANTS (Place Of Death: steve oF fect /Date of Registration: 16/11/2021 fiz 3 ea am fey gfimrays! VPO DADA DISTT HOSHIARPUR fipe ets mites ‘ seer iar use) Address of Deceased at the time of death Permanent Address of he Deceased gz 35a er fay gfreug / VPC DADA DISTT fiz 33a xe fre gfimreud / VPO DADA DISTT HOSHIARPUR HOSHIARPUR issuance 29/11/2021 ‘Signature of the Issuing Authority aa fte as Signed By: Raj Kumar Sign Date: 29/11/2021 1:45PM -, Designaton: Sub Registar carp end sin Sthcate printing cone) location, PHC Harte Bada = DOCUMENT VERIFIED AND PHYSICAL VERIFICATION DONE Tra as 1969 STS 12 ME tre HoH NS AS SieEaS far 2008 8 a ‘ofthe Registration of Binhs and Deaths Act, 1969 end rule 8 ofthe Punjab Repistation of Sis and Destns ules 2004 eee Pere Date 257112027