FORM NO.

1 BIRTH REPORT BIRTH REPORT In the case of multiple births, fill in a separate
(See Rule 5) Statistical Information form for each child and write ‘Twin birth’ or FORM No.1
Legal Information ‘Triple birth’ etc., as the case may be, in the remarks (See Rule 5)
This part to be detached and send for Statistical Processing column in the box below left.
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 : (Enter the exact day, month 10. Town or Village of Residence of the mother : (Place where the mother 16. Age of the mother (in completed years)
and year the child was born e.g. 1-1-2000) 26/09/2024 usually lives. This can be different from the place where the delivery at the time of marriage : 21
occurred. The house address is not required to be entered.) (If married more than once, age at first
marriage may be entered)
2. Sex : (Enter “Male, or “ Female”) a) Name of Town/Village : LUMDING 17. Age of the mother (in completed years)

-------------------To be detached and sent for statistical Processing --------------------------------------------------

do not use abbreviation) FEMALE at the time of this birth : 24+
b) Is it a town or village : (Tick the appropriate entry below)
3. Name of the child, if any : B KAUSHALYA
(If not named, leave blank) 1. Town 2. Village
18. Number of children born alive to the
4. Name of the father : B KUMAR c) Name of District :HOJAI mother so far including this child : 2
(Full name as usually written) (Number of children born alive to
UID No of Father (if any) d) Name of State : ASSAM include also those from
4 6 3 6 9 4 1 0 3 9 9 6 11. Religion of the Family : (Tick the appropriate entry below) earlier marriage(s), if any)

Name of the mother : B BOBITA 1.Hindu 2. Muslim 3.Christian

5. (Full name as usually written)
UID No of Mother (if nay) 4. Any other religion : (write name of the religion)
3 5 3 9 0 3 6 5 9 1 9 9 12. Father’s level of education : 19. Type of attention at delivery : (Tick the appropriate entry below)
1. Institutional – Government
(Enter the completed level of
6. Address of parents at the time of 2. Institutional– Private or Non-Government
education e.g. if studied upto class 11TH PASS
Birth of the Child LUMDING 'ASSAM' DISTRICT' HOJAI.
VII but passed only class VI, write 3. Doctor, Nurse or Trained midwife
7. Permanent address of parents: LUMDING Village class VI)
LOCO COLONY
Mobile No:8753926827 DISTRICT:-HOJAI 4. Traditional Birth Attendant
STATE:-ASSAM
WARD NUMBER:-8
5. Relatives or others
8. Place of birth : (Tick the appropriate entry 1,2 or 3 below and give the name of
the Hospital/Institution or the address of the house where the birth took 13. Mother’s level of education : 20. Method of Delivery : (Tick the appropriate entry below)
place) 1. Natural
(Enter the completed level of
9 pass 2. Caesarean
1.Hospital/ Institution Name education e.g. if studied upto class
& Address: LUMDING DIVISIONAL RAILWAY Hospital VII but passed only class VI, 3. Forceps/Vacuum
2.House Address : write class VI)
3. Others: 14 Father’s occupation : 21. Birth Weight (in kgs.) (if available) : 3KG
9. (If no occupation write ‘Nil’) BUSINESSMAN
Informant’s name :B KUMAR
LUMDING 15. Mother’s occupation : 22. Duration of pregnancy (in weeks) : 39 WEEKS
Address :LUMDING DISTRICT HOJAI (If no occupation write ‘Nil’) HOUSEWIFE
STATE:-ASSAM

(After completing
All columns 1 to 22,
Informant will put
--

date and signature here : )

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
Name : Code No.
Registration No: Registration date : Registration No: Registration date :
Registration Unit : District : Date of Birth :
Town/Village : District :
Tahsil : Sex : 1.Male 2.Female
Remarks : (If any)
Town / Village : Place of Birth : 1.Hospital / Institution 2. House
Registration Unit : Name and Signature of the Registrar
Name and Signature of the Registrar