| To be filled
by the informant |
| 1. |
Date of Birth : (Enter the exact
day, .........................................................................................................
month and year the child was born (e.g. 1-1-2000) |
| |
| 2. |
Sex : (Enter "Male or female", ...................................................................................................................
do not use abbreviation) |
| |
| 3. |
Name of the child, if any : ........................................................................................................................
(If not named, leave blank) |
| |
| 4. |
Name of the father : ...............................................................................................................................
(Full name as usually written) |
| |
| 5. |
Name of the mother : .............................................................................................................................
(Full name as usually written) |
| |
| 6. |
Name of the grandfather : (father's
side) .............................................................................................. |
| |
| 7. |
Name of the grandmother : (father's
side) ........................................................................................... |
| |
| 8. |
Place of birth : (Tick the appropriate entry 1
or 2 below and give the name ..........................................
of the Hospital/Institution or the address of the house where the
birth took place) |
| |
| |
|
| |
|
| 9. |
Informant's name : ..................................................................................................................................
Address : ..................................................................................................................................................
(After completing all columns 1 to 20, informant will put date and
signature here:) |
| |
| |
| |
Date: Signature
or left thumb mark of the informant |
1.