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