iz:i la- 5
FORM NO. 5
tUe izek.k & i=k
BIRTH CERTIFICATE
¼ tUe vkSj e`R;q jftLVªhdj.k vf/kfu;e] 1969 dh /kkjk 12@17 vkSj
jktLFkku tUe vkSj e`R;q jftLVªhdj.k fu;e] 2000 ds fu;e 8@13 ds v/khu tkjh fd;k x;k ½
( Issued under Section 12/17 of the Registration of Births and Deaths Act,1969 and Rule 8/13 of the
Rajasthan Registration of Births and Deaths Rules, 2000 )
;g izekf.kr fd;k tkrk gS fd fuEu fyf[kr lwpuk tUe ds ewy vfHkys[k ls yh xbZ gS tks fd ¼LFkkuh; {ks=k@LFkkuh; fudk; ½ ---------------------------------
------------------------ rglhy @[k.M ------------------------------------------------------------------------------ ftyk ------------------------------------------------------------------------------------------jkT;-@la?k jkT;
{ks=k-------------------------------------------------------------dk jftLVj gSA
This is to certify that the following information has been taken from the original record of birth which is the
register for (local area / locall body).................of
body)………………………….of tahsil / tahsil / block
block....VAISHALI
.……………………….NAGAR of
District....RAJASTHAN-302021 of state
uke@Name: KARTIK fyax@ Sex.....MALE
JAIPUR RAJASTHAN-302021
tUe frfFk@Date of Birth ....01/01/2020 tUe LFkku @Place of Birth …......................……………
ekrk dk uke@Name of Mother....SHAIL KUMARI
firk dk uke @ Name of Father.......RAMESH KUMAR
cPps ds tUe ds le; ekrk firk dk irk ekrk&firk dk LFkk;h irk
Address of parents at the time of birth of the child: Permanent address of parents:
……………………………....…………........…… ................................………………………………..
212, NEAR CRADLE CHILDREN HOSPITAL, NEMI MURA KARMWAR, MURAKARAMWAR, SIWAN
………………………………………............…… ………………................................………………..
NAGAR VAISHALI NAGAR, JAIPUR-302021 BIHAR, -841235
………………………………………............…… ……………................................…………………..
jftLVdj.k la-@ Registration No:. ...JAI77415 jftLVªhdj.k dh rkjh[k@ Date of Registration -01/01/2024
……............................
NO
fVIi.kh@Remarks(if any)………......................................................................................................…………………
01/01/2020
tkjh djus dh rkjh[k @ Date of issue:.....….................tkjhdjus okys izkf/kdkjh ds gLrk{kj@ Signature of the issuing authority
eqgj@Seal
