सं.

1
No. 1
हरयाणा सरकार प-6
GOVERNMENT OF HARYANA FORM-6
वाय सेवाएं वभाग
DEPARTMENT OF HEALTH SERVICES
नगर नगम गुराम
MUNICIPAL CORPORATION GURUGRAM

मृयु माण-प
DEATH CERTIFICATE

(जम मृयु रिजकरण अधनयम , 1969 क धारा 12 / 17 तथा हरयाणा जम मृयु रिजकरण नयम, 2002 के नयम 8/13 के अंतगत जार कया गया )

(ISSUED UNDER SECTION 12/17 OF THE REGISTRATION OF BIRTHS & DEATHS ACT, 1969 AND RULE 8/13 OF THE HARYANA REGISTRATION OF BIRTHS &
DEATHS RULES 2002.)

यह मािणत कया जाता है ननलिखत सूचना मृयु के मूल अभलेख से ल गई है जो क नगर नगम गुराम तहसील गुराम िजला गुराम राय/संघ देश
हरयाणा,भारत के रिजटर म उिलिखत है ।
THIS IS TO CERTIFY THAT THE FOLLOWING INFORMATION HAS BEEN TAKEN FROM THE ORIGINAL RECORD OF DEATH WHICH IS THE REGISTER FOR
MUNICIPAL CORPORATION GURUGRAM OF TAHSIL/BLOCK GURUGRAM OF DISTRICT GURUGRAM OF STATE/UNION TERRITORY HARYANA, INDIA.

मृतक का नाम / NAME OF DECEASED : VISHWAMBHAR LAL GUPTA लंग / SEX: पुरष / MALE

आधार नंबर / AADHAAR NO.:

XXXXXXXX2994

मृयु क तथ / DATE OF DEATH: मृयु का थान / PLACE OF DEATH:

03-02-2023 MEDANTA THE MEDICITY HOSPITAL GURGAON
THIRD-FEBRUARY-TWO THOUSAND TWENTY THREE
पत / पी का नाम / NAME OF HUSBAND / WIFE:
HANSHWATI GUPTA
मृतक क उ / AGE OF DECEASED:
79 YEARS आधार नंबर / HUSBAND/WIFE AADHAAR NO. :
XXXXXXXX2095

माता का नाम / NAME OF MOTHER: पता का नाम / NAME OF FATHER :

LATE RAM PYARI LATE MASURIYA DIN GUPTA

आधार नंबर / MOTHER'S AADHAAR NO. :

--- आधार नंबर / FATHER'S AADHAAR NO. :
---

मृयु के समय मृतक का पता / ADDRESS OF THE DECEASED AT THE TIME OF DEATH : मृतक का थायी पता / PERMANENT ADDRESS OF DECEASED :

109/1/123 - 15 K, 109/1/123 - 15 K,
RAJROOPPUR, GAYASDDINPUR UPRHAR, ALLAHABAD, PRAYAGRAJ, RAJROOPPUR, GAYASDDINPUR UPRHAR, ALLAHABAD, PRAYAGRAJ,
UTTAR PRADESH- 211011 UTTAR PRADESH- 211011

पंजीकरण संया / REGISTRATION NO: पंजीकरण तारख / DATE OF REGISTRATION:

D-2023: 6-90171-001508 16-02-2023

टपणी / REMARKS (IF ANY):

---

जार करने क तथ / DATE OF ISSUE: जार करने वाला ाधकार / ISSUING AUTHORITY
23-02-2023
रिजार (जम एवं मृयु)
REGISTRAR (BIRTH & DEATH)
MUNICIPAL CORPORATION GURUGRAM
नगर नगम गुराम

UPDATED ON :
2023-02-16

"THIS IS A COMPUTER 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.

" येक जम एवं मृयु का पंजीकरण सुनचत कर" / ENSURE REGISTRATION OF EVERY BIRTH AND DEATH "