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Declaration for corrections of Birth and Death entries
Circle/Location:
1 _s/0_
‘Aged about Years, working as
(Designation and complete address of the individual of the firm) residing at
(Complete Door No. street and station has to be stated with Telephone number)
Declared that
sy Delivered Male child/ Female child
Born/Died in (actual place of event) on
(Date of Event)
‘The Birth /Death certificate Issued on
The Name/s was wrongly informed by _ (The person who informs the
event has to be stated) please do the following corrections
Tn correct Name. To be corrected as
STATION:
Date: SIGNATURE OF THE DECLARANT
(Declarants Name in Capital Letters)
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1 Know Sei/smt (Ess)
s/o w/o.
asa resident of.
The signature of the Declarant is taken
‘my presence and contents mentioned by the Declarant are true and
correct to the best of my knowledge and belief.
a: z)
GAZETTED OFFICER GAZETTED OFFICER
Sign Seal & Sign &Seal &
(Name ofthe officer) (Name of the officer)
SC Transaction No. a No.
The following Documents should be produced by the Declarant for name corrections in Birth/Death registers.
1. Declaration by the nearest relative (parents/Childs/spouse) in case of death and either father or mother in
case of live Birth,
2. The declaration stated should be true and correct by two Gazatted officers (names of Gazatted officers are to
be written in Capitals)
3. Notary affidavit on (Rs. 10/. Non judicial Stamped paper).
4. The original Birth/Death certificates already taken are to be returned.
5. Documentary evidences ike educational certificates , election 1D card, Ration card, passport, Driving Licenses,
Marriage certificate, LIC policies, caste certificates, property papers, etc (evidence to be submitted before birth
‘of the child or Death of Deceased )
6. Consent letter from concerned Hospital regarding the correction to the effect.
7. Other child certificates if any.
8. Incase of Medico Legal death a) Post mortem report b) Form~2 by concerned police station
9 Any other support Documents if any please specify.
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