FORM N0.

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GOVERNMENTOFANDHRAPRADESH
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HEAL TH, MEDIC AL & FAMIL Y WELF ARE DEPAR TMEN T

~tSm ~e)~ al~ ~ I Death Certificate

~I() <futjra ~ ~cfu) 1 969, 1 2/17, g)~cfu) § [Link],, l!JO~§o~ IB~I() ;futjra @ ~ 10e.x><j5@ro 1
9 99, 8/1 3 /Ot)~~ ~015 ~ ~~ e'.l.
(Issued under Section 12/17 of the Registration of Births and deaths Act 1969 and Rules 8/13 of the Andhra
Pradesh Registration of Births and Deaths Rules 1999)
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·- - - ······--····..············ ---····:·...............................cfuol::ie>all:l
- - - -........................................................................................................... (~IO~
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This is to certify that the followi ng informa tion has been taken from the-orig
inal record of death, which is in the
registe r for (local area/ local body) ........... ........... ........... ......... of Manda
l ........... ........... ........... of Distric t
...... .. ....... ........... ........... ..... ........... ..... of State Andhra Prades h
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Name · ........... ........... ............ ............ ............ ............ ............ ............ ............ ............
Oo~~ ............ ............ ........ .
Sex · ........... ........... ........... ........... ........... ........... ........... ........... ........... ...........
........... ........... ........... .
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Date of Death · ........... ........... ........... ........... ........... ........... ........... ...........
........... ............ ............ ............ ............ ..
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Place of J?eath : ........... ........... ........... ........... ........... ........... ........... ...........
........... ........... ........... ........... ..--:- ........... .
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N;'me of Mother :......................................................................................................................................................
..................................
.j~ e!lc;,a(j ri'lo. / UID No. of Mother (if Any) LI _ j____.___...J....___,__ __,__ __,__ ~~-~ -~~-

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Addres s of the deceas ed at the time of Death Permanent Address of Deceased

;S~~ .So~s
Registration No. _ _ _ _ _ _ _ _ __
;S~~ ae
Date of Registration _ _ _ _ _ _ _ __ r5>S ~am eitpsao ' 6 ~ o'i>exm:> ~
e~~l- ~ Signature of the issuing authority and address
Remarks,_ _ _ __ _ _ _ _ __ __ teJJ / Seal
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Date of Issue' ....-- ----- ---'- :---
;;56 m,Mio'i>.J, 1§6· o'i>CSraoS.:
: · ~
u Bi2~ 21 fJiffi'eJ ~ r o ~ ~cmolll• I Ensure registration of every birth and death with in 21 days.
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