GOVERNMENT OF ODISHA DEPARTMENT OF HEALTH AND FAMILY WELFARE CERTIFICATE OF BIRTH Issued under Section 12/17 of the Registration of Births and Deaths Act, 1969 and Rules of Odisha Births and Deaths, Rule 2001 This is to certify that following information has been taken from the original records of birth which is in the register for of Tahasil of District of State ODISHA Dr Pradosh Kumar Panda Issuing Authority Registrar, Births & Deaths id="tk_1" class="t s6">(English Version) FORM NO-5 ISSUE NO : 143/2026 NAME: SEX: DATE OF BIRTH: PLACE OF BIRTH: NAME OF MOTHER: NAME OF FATHER: MOTHER'S ID PROOF NO: ******** FATHER'S ID PROOF NO: ******** ADDRESS OF PARENT AT THE TIME OF CHILD BIRTH: PERMANENT ADDRESS: REGISTRATION NO: REGISTRATION DATE: UBRN NO: 21UB370-0017-001751-2021 DATE OF ISSUE: THIS IS A COMPUTER GENERATED CERTIFICATE WHICH CONTAINS FASCIMILE SIGNATURE OF THE ISSUING AUTHORITY. It is a digitally signed electronically generated certificate and therefore needs no ink-signed signature,stamp or seal. This certificate is issued as per section 4,5 & 6 of information technology Act 2000 and it's subsequent amendments in 2008.For any query or verification, please visit https://www.birthdeath.odisha.gov.inTampering of this certificate will attract penal action. Digitally signed by Dr Pradosh Kumar Panda Date: Reason: Birth Certificate Location: Signature Not Verified