FORM-5
NO. 1 GOVERNMENT OF MANIPUR
DEPARTMENT OF MEDICAL HEALTH AND FAMILY WELFARE
SERVICES
CHANGAMDABI GRAM PANCHAYAT
BIRTH CERTIFICATE
(ISSUED UNDER SECTION 12/17 OF THE REGISTRATION OF BIRTHS & DEATHS ACT, 1969 AND RULE 8/13 OF THE MANIPUR 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 CHANGAMDABI GRAM PANCHAYAT OF TAHSIL/BLOCK KEIRAO BITRA OF DISTRICT IMPHAL EAST OF STATE/UNION TERRITORY
MANIPUR, INDIA.
NAME: KORIMAYUM ZUNIYED ANSARI SEX: MALE
AADHAAR NO.:
XXXXXXXX2377
DATE OF BIRTH: PLACE OF BIRTH:
01-09-2009 YAIRIPOK,CHANGAMDABI MATHAK LEIKAI,
FIRST-SEPTEMBER-TWO THOUSAND NINE CHANGAMDABI,KEIRAO BITRA, IMPHAL EAST,
MANIPUR, 795149
NAME OF MOTHER: NAME OF FATHER:
RUHINA SHAHANI KM RAFI SHAH
MOTHER'S AADHAAR NO: FATHER'S AADHAAR NO:
XXXXXXXX8226
XXXXXXXX9479
ADDRESS OF PARENTS AT THE TIME OF BIRTH OF THE CHILD: PERMANENT ADDRESS OF PARENTS:
YAIRIPOK,CHANGAMDABI MATHAK LEIKAI, CHANGAMDABI, , KEIRAO BITRA,
IMPHAL EAST, MANIPUR- 795149 YAIRIPOK,CHANGAMDABI MATHAK LEIKAI, CHANGAMDABI,
KEIRAO BITRA, IMPHAL EAST,
MANIPUR- 795149
REGISTRATION NUMBER: DATE OF REGISTRATION:
B-2023: 14-01772-000023 28-03-2023
REMARKS (IF ANY):
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DATE OF ISSUE: ISSUING AUTHORITY :
28-03-2023
SUB-REGISTRAR (BIRTH & DEATH)
CHANGAMDABI GRAM PANCHAYAT
UPDATED ON :
28-03-2023 09:11:31
"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 "
