Form 5

सं य /No. : JHBC/2010/534125

झारख ड सरकार
GOVERNMENT OF JHARKHAND
योजना ए वं िवकास िवभाग
(सां यक ए वं मू यांक न िनदे श ालय )

DEPARTMENT OF PLANNING AND DEVELOPMENT

(DIRECTORATE OF STATISTICS AND EVALUATION)
ज म माण -प / BIRTH CERTIFICATE

(ज म म ृ यु र ज ट ीक रण अ ध िनयम , 1969 क ध ारा 12/17 तथा झ ारखं ड ज म म ृ यु र ज ट ीक रण िनयम , 2009 िनयम 8/13 के अं त गत ज ारी िक या गया |)
(Issued under Section 12/17 of Registration of Births and Deaths Act, 1969 and Rule 8/13 of the JHARKHAND Registration of Births and
Deaths Rule 2009)

यह म ािण त िक या ज ाता है िक िन नांि क त सूच ना ज म के म ूल अिभ ले ख से ल ी गयी है ज ो िक ( थानीय े ) पं च ायत क ायाल य SAMRAM ख ड GAMHARIA
ज ल ा SARAIKELA KHARSAWAN रा य झ ारखं ड के र ज ट र म उि ख त है |
This is to certify that the following information has been taken from the original record of birth which is the register for (local area/body)
Panchayat Office-SAMRAM of Block -GAMHARIA of District-SARAIKELA KHARSAWAN of State Jharkhand.

नाम/ Name : YUVRAJ SINGH लिंग / Sex: Male

जन् म तिथि/ Date of Birth: 20/12/2009 ज म थान / Place of Birth : SAMRAM, Block - GAMHARIA,
तिथि/ Panchayat - SAMRAM, Village - GAMHARIA, SARAIKELA
KHARSAWAN (Jharkhand)

पिता का नाम / Name of Father : Shri. HARSH SINGH माता का नाम/ Name of Mother: Smt. SHWETA SINGH

ब चे के ज म के सम य म ाता िपता क ा पता /Address of Parents at the time म ाता िपता का थाई पता /
of birth of the child: SAMRAM (GAMHARIA). Permanent Address of Parents: SAMRAM (GAMHARIA).

पं ज ीक रण सं या / Registration Number : JHBC/2010/534125 पं ज ीक रण िदनाँक / Date of Registration : 09/01/2010

िट पण ी /Remarks(if any) :
िदनांक /Date of Issue : 13/12/2010

Digitally signed by Authorized Signatory

ा ध क ारी क ा पता / Address of Issuing Authority
SAMRAM : Panchayat Office
Sub-Division : SERAIKELLA, Block - GAMHARIA, District - SARAIKELA KHARSAWAN

"Ensure registration of every birth and death / ह र ज म औ र म ृ यु क ा पं जीक र ण सुि न च त क रे |"

This certificate has been generated and digitally signed by electronic system.
It is approved by authorized employee of related office.

Digitally signed by JAGANNATH MAHATO

Date: 2024.05.01 17:02:00 IST
Note: This is a Digitally Signed Certificate and does not require physical signature.This certificate can be verified at,
http://serviceonline.gov.in/userCertificate.html?tokenNo=8567023BxE989 by furnishing the Reference Number:-JHBC/2010/534125