Department of Heakh and Family Weitare/ fra m2 ufses ations Feat Delayed Registration of Birth J Fon Hsdifedte Gt Se TATgAS (Information form no. 1) Seay on enema T ee sea 30 days to 1 year (Rs 10) and After 1 year (Rs 20) Facilitation Chargos: R100 : eters oo Personal Data of Applicant! fibrve tor (These deta are ofthe person who is eppyng on behalf a bensfiiny of birth crtcae fee Baw Gn ened Fairedhete CoRR a rae wt ee [ NAVLEEN SINGH -SANTOKH LA) _MANIY BALA - | OF-07-2o04 a Melo (> Fema Wared Tj ed oe ESTAS IT — tas ie me _T HOS HI AR |15.Vilage Qh case of Rural Region only rrespondence address same aa permanent ediveas Note: "Taser nthe rena hagas craps reariEstegteue Aaesct Alen ae aan | ‘must be residing st this aderase fer mare than 6 morte, 7: Atass of Caneepondenaa™ ‘SAME “ADDRESS [acai saa fee PIN Code™ D1 otters (Pease mention th etond/ Be Oa (feo at fous gh) Personal Data of Beneficiary * __Reuiredintormetion — 25.Name ofthe chia We s™ Last Rev: Jul 2019 Page 1of7Home! Otters OH FS ES * | 33 (Q) Address of place oft (rlyin cave of | HENGE mame UY and THR HZ PO — DADA DIST HOSHARPOR- Rye, Powryr dolnlonaon OMarS hlornain ETS OTST SERA | WEST aa | Sareea |SpwToww val | T sh isms atten rere tres our” \vpo- DADA (RS Bar geap ao ost Hosraney a YT 40 Fil Non availablity corfcate(NAC) detae’ du Quoms Heduae Over = cr S.No| __Gtieaterormecite tes” | Daectisiswane/waoeGha” | romase/36@ | Towm/ ick | + _[BRIMACJOO6SS91781_ | 5-09-2024 [0F-01- dooy at 2 eal 3 4 | casethe wes srt) “41, Block affioe (office to which application to be sent ysrer CIWIE SURGEN GFFICE HoSHIARPUR Part-2 List of Required Documents equ err en IF. Please tick (\) the document attached | row west Sut ener § Ea (i) TB ‘SN ‘Namo of Document /Enr@a ea ‘Whether Mandatory ! Optional ga ea To ean Residence Proof of Applicant Late registration of bith —within one year/ Tem 3 eftmedan - flare ees [aa res | "RR A by gies FNS PIE Mandal AS 4 ‘Nan Availabilty Ceriicale paraiing tothe year of occurrence of vert ~ Mandatony TR >| | 4) Proof i ie hosp nang home port or van cro Waray Dal Bah | Wanda SP ‘Within one year) a ‘S| Witnesses of hwo credible persons Ste Sarpanchi Panciy Municipal Gounsicr! MLA MP or Gazatied Offender stato ro 14 Le __Late registration of bith ster one year/ ot 8 Be Sredis ame Cae TW cum Residence Proof of Applicant Wandaiony in all cases ‘Sei-deciaralon (par Precerbed Torna} mena Last Rev: Jul 2019, Page 3 of 7[Rchateormmeseearee | Many BALA a — BeFathera rane Area SANTORH Sy me 28, Gand har name SES ELA Oe am sor 2. Gender | ar* Male SH DD) Females Ci trasngender eareae 25, Father lion |RSS O™ Tsai Gn as 9. Date of bith / Hen Bis 08-07-2004 [Se eaRe TER oT i, Maral status / Teor weet chal oad Ty Widow ~T]Separatod 32, Soouse Name / Heard eo (only in case of beneficiary Is Married or Widowed ) rom aos" Qu YEAR 34, Ordor No of bith / HT Seaa | | 235, Address of parents atthe time of birth et AP ot Rise use * ieee PO -—DADA DIST HOSHARPUR mrw > Rood greg a Aw Procure ‘98. Permanent Address Of Parents! irs fis = rare? wenn PO - OADM DIST HOSHIARPUR ~~ mein RG md pred ITF Bie Preyer ‘BY Reason foriate entry /Be Wed aaeee was Place ofBieh details ona bar St wie BB la) Regisvaion Region Stuzeas wae 7 Ral “titan 30 0) Reistoton Deiat /redam tag» — | MOSHIARPUR | 99(0 Regstaton Teal strezan Pees | ‘36 (@) Place of birth Het ers * Ci Govt hospital ] Praia Hospital Fiome Last Rev: Jul 2019 podbot yonsecens | HOME se | # areeeic us Re Page 2 of 73.) Was fs cree parsons i Sarpancl Pani Nip Coanclod LAT WP or Gated (fcr under sat ne 1 (Mandotory if Dare of Death after one year) “Rn Araya oS ys sare patng Ws yaar men Toa PTO | of occurence and afr the yar of eccuranee Mandatory gS (i case tho event acu in curont year aso ats of aplication then inspite of alter the year ot ea cceurence, the record to be searched for pit pro yar of soerrence of event) | a oat Bt ie Nesp naring oe repo cate oT alee ST ay Manotry 7 gat © Copy of school erat or passpon or immunization card ting Hance oF sathar cnt cr voter Cardin case of Comic Bro any kor roo which shows data a place th, LE ‘| Gapyef bit oF shoal catia o passport ova Gard or ng isanse o auch Gard of ar twothertsister of chid where DO.B and Father name of sibs i merticed (ncase of Sigs) Mandatory / Eat : zs tre Declaratios Teo tae sae | sade fe Qader ne oe Se eneee Re yoo Na wead ne Ruem orS wong ae fer Reged gut od few | A fen de J Sal se ET Rr AaT Ra ore RA ae yor Yo MES IAS s Targa wows war e/a waters Setar / Beat ws wird Ba Hore TT 3 A FS ws raRs Ss Fea | | solemnly declare that the information provided as above and in attached documents is correct as per my belief and ‘no information has been hidden in this. 1 am aware of the fact that if any of the information provided by me is proved incorrect/wrong then I can be punished in the cout of law as per the provisions in the relevant Acts/rulesinotifications and depending upon this wrong information, all the benefits provided by government to me shall also be stopped immediately, ‘ficeIDated: Hasler Singh SewrearcemDectarant Citizen's Signature / Thumb Impression Last Rev: Jul 2019 Page 4 of 7a os See, Diwsyy ga welled way Beate Par ee Sg WR 32 yin ome Rw abe ate ame ae ee eas oe SiS, Br Tao mores ett Parveen ems wale 13. Seder a aes + faa tee ¥ is é sles aBeoyr net fey Prius, ent fis w duowe ot 1 7 Ht. a Ate yr § wat 3a 3 ew on Fe fer fis wr ofoe Bor T wee ew TT ea tm 2 usa/aadt w mar Fe fis RE fh 09-0 F 2o0y 3 afew Ma wot iy & wed eRe AB Os | Te 3 sAdta su gets BP. we TH Prosar fe afasur | Ei Qua Be firs § wet Meet OM nS EF wt Asa fit wo RIE g dl As & ow ul und aee de fe fuslas wees fer fer tis er cler endia 3 veer fet erwp awa ahs Sre-b es ZHU ARTSY C BRS) PR. Ser TAA Te ANG ap RR Sasa Sas & Fea) Re) to-t-2ah 3S BAS Fae A ou xs WS Qy 2.0. Da Distt. Hoshiarpurar __isration No: DRVES/21/0028480657 us Aaaa/ Government of Punjab g } frag 3 ufses S68 fest / Health and Family Welfare Department = “ j Ue afrreas Hen 3 3, UAT / Chief Registrar (Birth & Death), Punjab uz et wadifede/Death Certificate Fts WPH-369 a a Ria grdta dha ned fa do tnt quer ws Ws frees RO met ae S Hodt fa me aners, HON Sg, Ses Mea geet see stris ghoraus fray gfmrays une, 27s 2021 2 ofrned fee CaS «|S to certty that following information has been taken from the original death record which is registered in the death register of uo Registrar, Birth & Death Block PHC Herta Badia , Tehsil Hoshiarpur, District Hoshiarpur of Punjab State for the year 2021 31H IName of Deceased: Se"E UH / NARAIN DAS. Sex: ‘us| Male aecardt & ot / Spouse's ustg 841/ PRITU DEVI Name: ‘5 [Father's Name: ret TH / BAVA RAM “= S57 Mothers Name: — FeTst/ JUWALL “sat (Date Of Death: 40/11/2021 #3 MATT [Place Of Death SAZSAS S fist Date of Registration:16/11/2021 fis 3 ra ox fey afrsys ! VPO DADA DISTT HOSHIARPUR fsa eras mi use) fae deus Address of Deceased at the time of death Permanent Address of the Deceased Uz 3 33s wx fag gfrsus / VPO DADA DISTT fiz 3 ora oer fray gfmrays / VPO DADA DISTT HOSHIARPUR HOSHIARPUR ‘Signature ofthe Issuing Authority Signed By: Re Kumer Sign Date: 29/11/2021 1:45PM Designation: Sub Registrar Location PHC Harta Badia Strrcers tae 1969 Sh er 12 6 Une He wd as stemeSas fom 2008 @ fo 2 - Issued uls 12f the Registration of Binhs end Deaths Act, 1969 and rule 8 ofthe Punjab Registration of ae Princ Date 251172021