NAME OF DECEASED :

SEX :

DATE OF DEATH :

--

PLACE OF DEATH :

NAME OF HUSBAND / WIFE:

AGE OF DECEASED :

NAME OF MOTHER :

NAME OF FATHER:

AADHAAR NUMBER OF MOTHER:

> XXXXXXXX

AADHAAR NUMBER OF FATHER :

XXXXXXXX

ADDRESS OF THE DECEASED AT THE TIME OF DEATH /
:

PERMANENT ADDRESS OF DECEASED :

REGISTRATION NUMBER:

DATE OF REGISTRATION :

REMARKS (IF ANY) :

DATE OF ISSUE :

S.No. 1

सं. 1

FORM 5

प्रपत्र-6

Updated On:

‘ThisQRcodecanbeusedtochecktheauthenticityofthe

certificate’

SIGNATURE OF ISSUING AUTHORITY / जारी करने वाला प्राधिकारी:

"ENSURE REGISTRATION OF EVERY BIRTH AND DEATH / প্রতিটি জন্ম- মৃত্যু নিবন্ধীকরণ সুনিশ্চিত করুন"