Key No. B0021080-1308303 FORM No.5 (See Rule 8)

tIcf kÀ¡mÀ GOVERNMENT OF KERALA

]©mb¯v hIp¸v DEPARTMENT OF PANCHAYAT kÀ«n^n¡äv \ðIp¶ Xt±iØm]\¯nsâ t]cv A¼ehbð {Kma ]©mb¯v Name of Local Government issuing certificate Ambalavayal Grama Panchayat

P\\ kÀ«n^n¡äv BIRTH CERTIFICATE (Issued Under Section 12)

(1969þse P\\þacW cPnkvt{Sj³ BIvSnse 12þmw hIp¸pw 1999þse tIcf P\\þacW cPnkvt{Sj³ N«§fnse 8þmw N«hpw A\pkcn¨v \ðIp¶Xv). (Issued under Section 12 of the Registration of Births and Deaths Acts, 1969 and Rule 8 of the Kerala Registration of Births and Deaths Rules, 1999)

Xmsg ]dbp¶ hnhc§Ä tIcf kwØm\¯nse hb\mSv Pnñbnse kpð¯m³ _t¯cn Xmeq¡nse A¼ehbð {Kma ]©mb¯v þse (Xt±iØm]\w) AÊð P\\ cPnÌdnð \n¶v FSp¯n«pÅhbmsW¶v km£ys¸Sp¯p¶p. This is to certify that the following information has been taken from the original record of birth which is the register for (local area/local body) Ambalavayal Grama Panchayat of Taluk Sulthan Bathery of District Wayanad of State Kerala.

---t]cv/ Name ---B¬/s]¬/ Sex

:

{ipX IoÀ¯n. BÀ.Fkv / SRUTHA KEERTHI. R.S

:

B¬/ Male

---P\\ XobXn/ Date of Birth

:

10/08/2013 TEN/AUGUST/TWO THOUSAND THIRTEEN

---P\\ Øew/ Place of Birth

:

ado\ tlmkv]näð, A¼ehbð/ Marina Hospital, Ambalavayal

---amXmhnsâ t]cv / Name of Mother ---]nXmhnsâ t]cv/ Name of Father

:

kuay sI Fw / Soumya K M

:

cmtPjv sI Ip\nbnð / Rajesh K Kuniyil

Ip«nbpsS P\\ kab¯v amXm]nXm¡fpsS taðhnemkw

:

k]cy lukv,samS¡ñqÀ ]n H, tImgnt¡mSv, tIcfw, C³Uy

Address of the parents at the time of birth of the child

:

Saparya House,Modakkallur P O, Kozhikode, Kerala, India

amXm]nXm¡fpsS Øncamb taðhnemkw

:

k]cy lukv,samS¡ñqÀ ]n H, tImgnt¡mSv, tIcfw, C³Uy

Permanent address of parents

:

Saparya House,Modakkallur P O, Kozhikode, Kerala, India

cPnkvt{Sj³ \¼À/ :

cPnkvt{Sj³ XobXn/ : 03/09/2013

548/2013

Registration Number

Date of Registration

---A`n{]mb¡pdn¸v/ Remarks (if any)

:

---\ðIp¶ XobXn/ Date of Issue

:

28/06/2016 (09:29)

:

Registrar of Births and Deaths ,

\ðIp¶ A[nImcnbpsS taðhnemkw/ Address of the issuing authority

Last Updated on 23/06/2016 (18:53)

Ambalavayal Grama Panchayat

“Ensure Registration of Every birth and death”

“Hmtcm P\\hpw acWhpw cPnÌÀ sNbvXpsh¶v Dd¸phcp¯pI” This certificate is computer generated and does not require any Seal/Signature in original The Govt. vide G.O.(Ms) No.202/2012/LSGD dated 25/07/2012 has approved this certificate as a valid document for all official purposes Authenticity of this certificate can be verified at www.cr.lsgkerala.gov.in. The Key Number is unique to each event. Software developed and supported by Information Kerala Mission. Certificate printed before the last updated date is invalid Page 1/1