सं.

1 उर देश सरकार प-5

NO. 1 GOVERNMENT OF UTTAR PRADESH FORM-5
चकसा एवं वाय वभाग
DEPARTMENT OF MEDICAL AND HEALTH
ाथमक वाय क ईसानगर
PRIMARY HEALTH CENTRE ISSANAGAR

जम माण-प
BIRTH CERTIFICATE

(जम मृयु रिजकरण अधनयम, 1969 क धारा 12 / 17 तथा उर देश 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 UTTAR PRADESH REGISTRATION
OF BIRTHS & DEATHS RULES 2002)

यह मािणत कया जाता है ननलिखत सूचना जम के मूल अभलेख से ल गई है जो क ाथमक वाय क ईसानगर तहसील धौरहरा िजला खीर
राय/संघ देश उर देश, भारत के रिजटर म उिलिखत है ।
THIS IS TO CERTIFY THAT THE FOLLOWING INFORMATION HAS BEEN TAKEN FROM THE ORIGINAL RECORD OF BIRTH WHICH IS THE REGISTER
FOR PRIMARY HEALTH CENTRE ISSANAGAR OF TAHSIL/BLOCK DHAURAHARA OF DISTRICT KHERI OF STATE/UNION TERRITORY UTTAR PRADESH,
INDIA.

नाम / NAME: AYANSH MISHRA लंग / SEX: पुरष / MALE

जम तथ / DATE OF BIRTH:

जम थान/ PLACE OF BIRTH:
07-04-2023
PHC ISSANAGAR
SEVENTH-APRIL-TWO THOUSAND TWENTY THREE

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

RAM DEVI SANDEEP KUMAR

आधार नंबर / MOTHER'S AADHAAR NO: आधार नंबर / FATHER'S AADHAAR NO:
XXXXXXXX7246
XXXXXXXX4384

बचे के जम के समय माता-पता का पता / ADDRESS OF PARENTS AT THE TIME माता-पता के थायी पता/ PERMANENT ADDRESS OF PARENTS:
OF BIRTH OF THE CHILD:

CHANDRASA KHURD, , DHAURAHARA, KHERI, UTTAR PRADESH- 261502 CHANDRASA KHURD, DHAURAHARA, KHERI,
UTTAR PRADESH- 261502

पंजीकरण संया / REGISTRATION NUMBER: पंजीकरण तारख / DATE OF REGISTRATION:

B-2023: 9-56945-000387 26-07-2023

टपणी / REMARKS (IF ANY):

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जार करने क तथ / DATE OF ISSUE: जार करने वाला ाधकार / ISSUING AUTHORITY :
26-07-2023
रिजार (जम एवं मृयु)
REGISTRAR (BIRTH & DEATH)
ाथमक वाय क ईसानगर
PRIMARY HEALTH CENTRE ISSANAGAR

UPDATED ON :
26-07-2023 08:08:40

"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 DOCUMENT FOR ALL OFFICIAL PURPOSES".

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