Form-5

GOVERNMENT OF WEST BENGAL

DEPARTMENT OF HEALTH AND FAMILY WELFARE

FALAKATA SUPER SPECIALITY HOSPITAL

BIRTH 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 BIRTH WHICH IS
THE REGISTER FOR FALAKATA SUPER SPECIALITY HOSPITAL OF BLOCK/MUNICIPALITY MUNICIPALITY FALAKATA OF DISTRICT
ALIPURDUAR OF STATE WEST BENGAL, INDIA.

NAME : ADITYA DAS GENDER : MALE

DATE OF BIRTH : 14/09/2022 PLACE OF BIRTH : FALAKATA SUPER SPECIALITY

HOSPITAL, MUNICIPALITY FALAKATA,
ALIPURDUAR, WEST BENGAL

NAME OF MOTHER : SAMPA DAS NAME OF FATHER : SANJAY DAS

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

XXXXXXXX0856

PRESENT ADDRESS OF MOTHER VILLAGE/TOWN:- SATPUKURIA,FALAKATA BLOCK,DIST:- ALIPURDUAR,WEST BENGAL-

AT THE TIME BIRTH OF THE
CHILD :

PERMANENT ADDRESS OF VILLAGE/TOWN:- SATPUKURIA,FALAKATA BLOCK,DIST:- ALIPURDUAR,WEST BENGAL-

MOTHER :

CERTIFICATE NO : B/2022/458964 DATE OF REGISTRATION : 24/09/2022

S-UHID : 41986823290023 REMARKS (IF ANY) :

DATE OF ISSUE : 24/09/2022 ISSUING AUTHORITY :

UPDATED ON : 2022-09-24 13:27:56

Signature Not Verified

Digitally Signed.
Name: KRISHNENDU BISWAS
Date: 24-Sep-2022 13:59:06

SUB-REGISTRAR (BIRTH & DEATH)

FALAKATA SUPER SPECIALITY
HOSPITAL

"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 "