FORM-5

NO. 1 GOVERNMENT OF ASSAM

DEPARTMENT OF HEALTH AND FAMILY WELFARE
AMSOI STATE DISPENSARY, NAGAON

BIRTH CERTIFICATE

(ISSUED UNDER SECTION 12/17 OF THE REGISTRATION OF BIRTHS & DEATHS ACT, 1969 AND RULE 8/13 OF THE ASSAM
REGISTRATION OF BIRTHS & DEATHS RULES 1999)

THIS IS TO CERTIFY THAT THE FOLLOWING INFORMATION HAS BEEN TAKEN FROM THE ORIGINAL RECORD OF BIRTH WHICH IS
THE REGISTER FOR AMSOI STATE DISPENSARY, NAGAON OF TAHSIL/BLOCK RAHA OF DISTRICT NAGAON OF STATE/UNION
TERRITORY ASSAM, INDIA.

NAME: ASHOK KONWAR SEX: MALE

DATE OF BIRTH: PLACE OF BIRTH:

25-11-2023
TWENTY-FIFTH-NOVEMBER-TWO THOUSAND TWENTY THREE AMSOI,RAHA, NAGAON,
ASSAM, 782425

NAME OF MOTHER: NAME OF FATHER:

ALOKA AMSI KONWAR SIMANTA KONWAR

MOTHER'S AADHAAR NO: FATHER'S AADHAAR NO:

XXXXXXXX1186

ADDRESS OF PARENTS AT THE TIME OF BIRTH OF THE CHILD: PERMANENT ADDRESS OF PARENTS:

AMSOI, , RAHA, NAGAON, ASSAM- 782425 178, TUPAKUCHI,

DUMAIHAGI DAPARA, LUTUMARI N.C., KAMPUR, NAGAON,
ASSAM- 782428

REGISTRATION NUMBER: DATE OF REGISTRATION:

B-2024: 18-00301-000001 01-01-2024

REMARKS (IF ANY):

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DATE OF ISSUE: ISSUING AUTHORITY :

01-01-2024
REGISTRAR (BIRTH & DEATH)

AMSOI STATE DISPENSARY, NAGAON

UPDATED ON :
01-01-2024 00:00:00

"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".

ENSURE REGISTRATION OF EVERY BIRTH AND DEATH "