Form-5
GOVERNMENT OF WEST BENGAL
DEPARTMENT OF HEALTH AND FAMILY WELFARE
MALDA MEDICAL COLLEGE & HOSPITAL
BIRTH CERTIFICATE
(ISSUED UNDER SECTION 12/17 OF THE REGISTRATION OF BIRTHS & DEATHS ACT, 1969 AND RULE 8/13 OF THE WEST
BENGAL
THIS IS TO CERTIFY THAT THE FOLLOWING INFORMATION HAS BEEN TAKEN FROM THE ORIGINAL RECORD OF BIRTH
WHICH IS THE REGISTER FOR MALDA MEDICAL COLLEGE AND HOSPITAL OF TAHSIL/BLOCK OF DISTRICT MALDA OF
STATE/UNION TERRITORY WEST BENGAL, INDIA.
NAME : TIYASA DAS GENDER : FEMALE
DATE OF BIRTH : 24-01-2017 PLACE OF BIRTH : MALDA MEDICAL COLLEGE & HOSPITAL
NAME OF MOTHER : RIYA DAS NAME OF FATHER : SANJOY DAS
MOTHER'S IDENTITY PROOF: XXXX-XXXX-5031 FATHER'S IDENTITY PROOF: -
PRESENT ADDRESS OF MOTHER
AT THE TIME BIRTH OF THE 14 A DUMDUM ROAD GHUGUDANGA KOLKATA WEST BNEGAL 700030
CHILD
PERMANENT ADDRESS OF 14 A DUMDUM ROAD GHUGUDANGA KOLKATA WEST BNEGAL 700030
MOTHER:
CERTIFICATE NO : B-2024: 10-90347-00696 DATE OF REGISTRATION :24-01-2017
S-UHID : 98870991528534 REMARKS (IF ANY) :
DATE OF ISSUE : 25-01-2017 ISSUING AUTHORITY :
UPDATED ON : 24-01-2017 04:58:37
Signature Valid
Digitally Signed.
Name:
Date: 24-01-2017 04:58:37
REGISTRAR (BIRTH & DEATH)
MALDA MEDICAL COLLEGE & HOSPITAL
"THIS IS A COMPUTER GENERATED CERTIFICATE."
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"
