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Form No. 1 Birth Report Birth Report Form No.1 Legal Information Statistical Information

Soumyadip Hazra was born on June 3rd, 2022 in Kashijora, West Bengal to parents Amiya Hazra and Purnima Hazra. Soumyadip was born at home, a male weighing 5.6 kgs at 40 weeks gestation. Purnima Hazra, age 0 at her first marriage and birth, had one previous live birth. The family's religion is Hindu and they reside in Kashijora.

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Abhi Hazra
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3K views2 pages

Form No. 1 Birth Report Birth Report Form No.1 Legal Information Statistical Information

Soumyadip Hazra was born on June 3rd, 2022 in Kashijora, West Bengal to parents Amiya Hazra and Purnima Hazra. Soumyadip was born at home, a male weighing 5.6 kgs at 40 weeks gestation. Purnima Hazra, age 0 at her first marriage and birth, had one previous live birth. The family's religion is Hindu and they reside in Kashijora.

Uploaded by

Abhi Hazra
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Ref. No.

:
Form No. 1 BIRTH REPORT BIRTH REPORT Form No.1
Legal information Statistical information (See Rule 5)
1. Date of Birth: 06-03-2022 10. Town or Village of Residence 16. Age of the mother (in completed
of the mother: years) at the time of first
marriage:0
2. Sex: Male
3. Name of the child, if any: a) Name of 17. Age of the mother (in completed
Town/Village:Kashijora years) at the time of this birth: 0
SOUMYADIP HAZRA
4. Name of the b) Is it a town or 18. Number of children born alive to
father:AMIYA HAZRA village:Village the mother so far including this
child: 1
UID No of Father (if any): c) Name of District: Paschim 19. Type of attention at delivery:
Medinipur Traditional Birth Attendant
d) Name of State: West
Bengal
5. Name of the 11. Religion of the Family:Hindu 20. Method of Delivery:
mother:PURNIMA HAZRA
UID No of Mother (if any): Any other religion: 21. Birth Weight (in kgs.): 5.600
12. Father’s level of education:
6. Address of parents at the time Primary 22. Duration of pregnancy (in weeks):
of Birth of the Child:
Kashijora Kashijora Medinipur, 13. Mother’s level of education:
Medinipur Municipality,
Paschim Medinipur, West
Bengal, 721129
7. Permanent address of parents: Literate without formal
education
Kashijora Kashijora Medinipur, 14. Father’s occupation:
Medinipur Municipality,
Paschim Medinipur, West
Bengal, 721129
8. Place of birth: Non worker
N0120 Kashijora 15. Mother’s occupation:
Medinipur, Medinipur
Municipality, Paschim
Medinipur, West Bengal
721129
9. Informant’s name: hazraov225

Signature or left thumb


mark of the informant
Date: 07-03-2022
TO BE FILLED BY THE REGISTRAR
Registration No.: District: Paschim Medinipur Registration No:
Registration Date: Sub-District: Medinipur Registration Date:
Municipality
Registration Unit: Medinipur Town/Village: Medinipur Date of Birth: 06-03-2022
Medical College And Hospital
Town/Village: Medinipur Registration Unit: Medinipur Sex: Male
Medical College And Hospital
District: Paschim Medinipur Place of Birth: House
Remarks (if any):
Name and Signature of the Name and Signature of the Registrar
Registrar
NOTE: - Please forward print out of this reporting form duly signed along with supporting documents to
the REGISTRAR (BIRTH & DEATH), MEDINIPUR MEDICAL COLLEGE AND HOSPITAL,
VILLAGE/TOWN: MEDINIPUR, SUB-DISTRICT: MEDINIPUR MUNICIPALITY, DISTRICT:
PASCHIM MEDINIPUR, STATE: WEST BENGAL

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