D.P.H.

368

Form No. 10 (See Rule 9)

DEATH CERTIFICATE Chief Registrar (Birth & Death) Punjab, Chandigarh

It is certified that the Information written below has been taken from the original Birth Record which is registered in the Register of Local Registrar Birth & Death MUNICIPAL COMMITTEE, SANGRUR, Tehsil SANGRUR District SANGRUR State Punjab. Name : Amarjeet Singh Hari Singh Indian Male 17/02/1991 Sangrur Registration No. : 65 22/02/1991 Permanent Address : Magzine Street Sangrur (Pb)

Fathers Name : Nationality Sex : :

Date of Death : Place of Death :

Date of Registration :

Certificate preparing persons Signature

Certificate issuing persons Signature Name : Kulwant

Name : Jaswant Singh

Stamp Local Registrar, Birth & Death Municipal Committee, Sangrur Date : 11/04/1991

Note :- This Certificate (Death) has been issued under the Birth & Death Registration Act 1969 (India Govt.) Section 12/17. What cause of death has been told in the Death register, That information will not be given in the Death Certificate