Form No. 1 Birth Application No : 5105526 Form No.

1
BIRTH REPORT BIRTH REPORT In the case of multiple births, fill in a separate form for each
Statistical information child and write 'Twin birth' or 'Triple birth' etc., as the case
Legal information may be, in the remarks column in the box below left
This part to be detached and sent for statistical processing
This part to be added to the Birth Register

To be filled by the informant To be filled by the informant To be filled by the informant

1. Date of Birth : 02/05/2023 10. Town or Village of 16. Age of the mother(in completed 20
Residence of the mother : years) at the time of marriage:
2. Sex : Female a) Name of State : GUJARAT 17. Age of the mother(in competed 22
years) at the time of the birth:
3. Name of the child : / b) Name of District : Surat 18. Number of children born alive to 1
the mother so far including this
child :
4. Name of the father : ɅkUhWjehˆU‘DSUDANI HARDIK c) Name of Taluka Surat(C) Female : 1

5. Name of the mother: \h_SjZpWɅkUhWjMALTI BEN SUDANI d) Name of Town or sachin Male : 0
Village :
6. Address of Parents zxx]sFpĖ^WF^DWDȶk^d‡IW e) Is it a Town or Village 19. Type of attention at Delivery : Institutional ±Private, Non
at the time of Birth Village : Government
YOGESHWAR NAGAR KANAKPUR SACHIN
of the Child
7. Permanent zxx]sFpĖ^WF^DWDȶk^d‡IW 11. Religion of the Family : Hindu 20. Method of Delivery : Natural
address of parents :
YOGESHWAR NAGAR KANAKPUR SACHIN
8. Place of Birth : TRUPTI HOSPITAL AND MATERNITY HOME 12. Father's level of Matric but below Graduate 21. Birth Weight(in kgs.): 2.5
SURAT education :
Address : 5 VRUNDAVAN ROW HOUSE VANZ ROAD, 13. Mother's level of Below Primary 22. Duration of Pregnancy(in weeks) : 38
SACHIN, SURAT. education :
9. Informant 's name : HARDIK 14. Father's occupation : Professional, Technical and Birth application no : 5105526
Related works
Address : 2009 YOGESHWAR NAGAR KANAKPUR 15. Mother's occupation : Non-workers
SACHIN
Birth application no : 5105526

Date : Signature or left thumb mark of the informant (Columns to be filled are over. Now put signature at left)

To be filled by the Registrar To be filled by the Registrar

Registration No : Registration Date : State : Gujarat Code No. Registration No :

Town/Village: South Zone B Tahsil: Surat(C) Date of Birth : 02/05/2023

District : Surat Town/Village : South Zone B Sex : Female

Remarks : Registration Unit: South Zone B Place of Birth: TRUPTI HOSPITAL AND MATERNITY HOME
SURAT
Name and Signature of the Registrar Name and Signature of the Registrar

Courtesy : National Informatics Center Print Time :-05/03/2023 12:54:02 PM