W a5) FORM NO. 5 OA WAM — Gat BIRTH CERTIFICATE (rr ste ar shanties oa, 1969 HTT 12/17 SI seater os ote gra forages Pas, 1209 3 Prong /13 3 ah TA at TAT) (Issued under Section 12/17 of the Registration of Births and Deaths Act,1969 and Rule 8/13 of the Madhya Pradesh Registration of Births and Deaths Rules, 1999 ) sae ene fora rer & fo Pr foe oT es oS Ra a a aE 8 Tats ee eye a arene This is to certify that the following information has been taken from the original record of birth which is the register for (local area / local body)....... senso tahsil / block ...... severe Off District... of state / Union territory ... FT /Name? oo sseeeeeeeeeee a eens FA/ Se. Ee ‘FA f/Date of Birth FTW /Place of Birth wret=t arH/Name of Mother... ftcr oI am / Name of Father. wea werd arr ane fer ToT ser Aen ar ear Address of parents at the time of birth of the child: Permanent address of parents: ‘forreme a Registration No: ss siegiavm a ATT / Date of Registration fee /Remarks(if any) ‘Fa FAA aA / Date of issue... ooo ATES TH MRE # EATERY Signature of the issuing authority wrfiee? ar srtent arom / Address of the issuing authority Ev/Seal