PUNJAB RIGHT TO SERVICE ACT 2011

HEALTH DEPARTMENT, PUNJAB

FORM FOR SEEKING SERVICE

Service asked for: ISSUANCE OF BIRTH CERTIFICATE (Stipulated Time 2 days for current year
and 5 days for previous year)
1. Date of Application
2. Name of the Applicant
3. Fathers/ Husbands Name
4. Residential Address Village/ Town Post Office
Tehsil District
Phone/Mobile No.
E-mail ID, (if any)
5. Name of the Child
6. Sex (Male/ Female)
7. Fathers Name
8. Fathers Father Name
9. Name of Childs Mother
10. Date of Birth of Child
11. a) Place of Birth (At Home)
Write the name of Village in case of Rural Area.
Write complete address in case of Urban Area.
b) Place of Birth ( Institutional Birth)
Write complete name of Hospital/Nursing
Home.
12. In case of Rural Area Birth-
Write name of Police Station if the child is born
before 31.12.2003.
Write name of Revenue Block in case of child is
born between 01.01.2004 to 30.09.2010.
Writ name of PHC/ CHC if the child is born
after 01.10.2010.
Note: - If the Birth is registered as delayed registration in rural area
then any one of Police Station/ Revenue Block/ PHC may be
written accordingly keep in view the year of registration.

In case Child is born in Urban Area then name

of the Municipal Corporation / Council / Nagar
Panchayat be given.
13. No. of Copies of Certificate required
14. Documents to be Attached Nil
15. Signature/ Thumb Impression of the Applicant
FOR OFFICE USE

1. Acknowledgement 2. Date
Receipt No.
3. Date by which service to 4. Fees/ Facilitation Fee Rs.15/- (One copy, One Year)
be provided Charges, if any
(Additional Search fee for One
Year Rs.5/- & Fees for additional
Copy of Certificate Rs.10/- per
Copy)
5. Name of Designated 6. Designation
Officer
7. Location 8. Signature of
D.O./Receiving Officer

.
ACKNOWLEDGEMENT SLIP
1. Acknowledgement 2 Date
Receipt No. .
3. Date by which service 4 Fees/ Facilitation
to be provided . Charges ( if any)
5. Service asked for Issuance of Birth Certificate
6. Documents Attached Nil
7.(a Name of Designated (b Designation
) Officer )
(c) Location (d Signature of
) Designated Officer

It is your right to seek service within stipulated time limit.

 PUNJAB RIGHT TO SERVICE ACT 2011
HEALTH DEPARTMENT, PUNJAB
FORM FOR SEEKING SERVICE

Service asked for: ISSUANCE OF DEATH CERTIFICATE (Stipulated Time 2 days for current
years and 5 days for previous years)
1. Date of Application
2. Name of the Applicant
3. Fathers/ Husbands Name
4. Residential Address Village/ Town Post Office
Tehsil District
Phone/Mobile No.
E-mail ID, (if any)
5. Name of the Deceased
6. Sex (Male/ Female)
7. Deceased Father/Husbands Name
8. Deceased Mother Name
9. Date of Death of Deceased
10. a) Place of Death (At Home)
Write the name of Village in case of Rural Area.
Write complete address in case of Urban Area.
b) Place of Death (Institutional Deaths)
Write complete name of Hospital/Nursing
Home.
11. In case of Rural Area Deaths
Write name of Police Station if the Death took
place before 31.12.2003.
Write name of Revenue Block in case Death
occurred between 01.01.2004 to 30.09.2010.
Writ name of PHC/ CHC if the Death took
Place after 01.10.2010.
Note:- If the Death is registered as delayed registration in rural
area then any one of Police Station/ Revenue Block/ PHC may be
written accordingly keep in view the year of registration.

In case Death took place in Urban Area then

name of the Municipal Corporation / Council /
Nagar Panchayat be given.
12. No. of Copies of Certificate required
13. Documents Attached Nil
14. Signature/ Thumb Impression of the Applicant
FOR OFFICE USE

1. Acknowledgement 2. Date
Receipt No.
3. Date by which service to 4. Fees/ Facilitation Fee Rs.15/- (One copy, One Year)
be provided Charges, if any
(Additional Search fee for One
Year Rs.5/- & Fees for additional
Copy of Certificate Rs.10/- per
Copy)
5. Name of Designated 6. Designation
Officer
7. Location 8. Signature of D.O./
Receiving Officer

......
ACKNOWLEDGEMENT SLIP
1. Acknowledgement 2. Date
Receipt No.
3. Date by which service 4. Fees/ Facilitation
to be provided Charges ( if any)
5. Service asked for Issuance of Death Certificate
6. Documents Attached Nil
7.(a Name of Designated (b) Designation
) Officer
(c) Location (d) Signature of
Designated Officer

It is your right to seek service within stipulated time limit.

 gzikp ;/tk nfXeko ekB{zB ^2011
pMjwb syvw AiDkwr kwnMUn 2011
;/tk b?D bJh ckow (f;js s/ gfotko GbkJh ftGkr$ b'eb pkvhia, gzikp ;oeko)
ishq qy pirvwr BlweI ivBwg,pMjwb
syvw pwRpq krn leI Pwrm

wzrh rJh ;/tk L iBw ;oNhfce/N ikoh eotkT[Dk (smW sImw - 2 idn pihly swl leI Aqy 5 idn ipCly swl leI )

1. noih d/D dh fwsh

2. fpB?eko dk Bkw
3. fgsk$gsh dk Bkw
4. fojkfJ;ah gsk fgzv$;afjo vkeykBk
sfj;hb fiabk
c'B$w'pkfJb BzL
Jh^w/b nkJhHvhH ,
i/eo e'Jh j?
5. pZu/ dk Bkw
6. fbzr (bVek$bVeh)
7. fgsk dk Bkw
8. dkd/ dk Bkw
9. pu/ dh wksk dk Bkw
10. pu/ dh iBw fwsh
11. T) iBw;EkB(xo ftZu )
g/Av{ y/so bJh fgzv dk Bkw
fbfynk ikt/.
;afjoh y/so bJh g{ok gsk fbfynk
ikt/.
n) iBw ;EkB ( ;z;Ek ftZu j'J/ iBw)
j;gskb$ Bof;zr j'w dk g{ok gsk
fbfynk ikt/.
12. g/Av{ y/so ftZu j'J/ iBw bJh
31^12^2003 s'A gfjbK iBw/ pZu/
bJh EkD/ dk Bkw fbfynk ikt/.
1^1^2004 s'A 30^9^2010 d"okB
iBw/ pZu/ bJh phHvhHghHUH pbke
dk Bkw fbfynk ikt/.
1^10^2010 s'A pkd iBw/ pZu/ bJh
ghHn?uH;hH$;hHn?uH;hH dk Bkw
fbfynk ikt/
(B'NL i/eo b/N nzdoki j? sK
EkDk$phHvhHghHU pbke$ghHn?uH;hH dk
Bkw ;kb nB[;ko fbfynk ikt/
i/eo pZuk ;afjoh y/so ftZu g?dk
j'fJnk j? sK Bro fBrw$ e';b $
Bro gzukfJs dk Bkw
13. ;oNhfce/N dh fezBhnK ekghnK
b'VhdhnK jB.(frDsh)
14. d;skt/ia i' Bkb BZEh eoB/ jB. e'Jh Bjh
15. fpB?eko d/ j;skyo $ nzr{m/ dk fB;akB
 dcsoh tos'A bJh

1. o;hd Bzpo 2. fwsh

3. ;/tk d/D dh fwsh 4. ch;$c?;hbhN/;aB ch; 15$^ WH(fJZe ekgh fJZe ;kb bJh) (tkX{
;kbK d/ foekov B{z bGD bJh 5 o[gJ/ gqsh ;kb
ukoi i/eo e'Jh j?
ns/ tkX{ ekghnK bJh 10 o[gJ/ gqsh ekgh)
5. nfXekos nfXekoh dk Bkw nZj[dk 6.
7. ;EkB nfXekos$gqkgs eosk
8.
nfXekoh d/ d;sys
.
(gqkgsh o;hd)
1. gqkgsh o;hd Bzpo 2. fwsh
3. ;/tk d/D dh fwsh
4. ch;$c?;hbhN/;aB, ukoi
i/eo e'Jh j?.
5. ;/tk i' wzrh j? iBw ;oNhfce/N ikoh eoB pko/
6H BZEh d;skt/i fBZb
7 (T) nfXekos nfXekoh dk Bkw (n) nj[Zdk
(J) ;EkB (;) nfXekos nfXekoh
d/ d;sys

;w/ f;o ;/tk gqkgs eoBk s[jkvk nfXeko j?.

 gzi
pMkp
jwb;/sytvk wnfXeko
AiDkwr ekB{
kwnMUnzB 2011
^2011
;/tk b?D bJh ckow (f;js s/ gfotko
ishq qy GbkJh ftGkr$
pirvwr BlweI b'ebjwbpkvhia, gzikp ;oeko)
ivBwg,pM
syvw pwRpq krn leI Pwrm

wzrh rJh ;/tk L w"s ;oNhfce/N ikoh eotkT[Dk (smW sImw - 2 idn pihly swl leI Aqy 5 idn ipCly swl leI )

1. noih d/D dh fwsh

2. fpB?eko dk Bkw
3. fgsk$gsh dk Bkw
4. fojkfJ;ah gsk fgzv$;afjo vkeykBk
sfj;hb fiabk
c'B$w'pkfJb BzL
Jh^w/b nkJhHvhHi/eo
e'Jh j?
5. fwqse dk Bkw
6. fbzr (g[o;a$fJ;soh)
7. fwqse d/ fgsk$gsh dk BK
8. fwqse dh wksk dk Bkw
9. w"s dh fwsh
10. T) w"s ;EkB(xo ftZu )
g/Av{ y/so bJh fgzv dk Bkw fbfynk
ikt/.
;afjoh y/so bJh g{ok gsk fbfynk
ikt/.
n) w"s ;EkB ( ;z;Ek ftZu j'Jh w"s)
j;gskb$ Bof;zr j'w dk g{ok gsk
fbfynk ikt/.
11. g/Av{ y/so ftZu j'Jh w"s bJh
31^12^2003 s'A gfjbK j'Jh w"s bJh
EkD/ dk Bkw fbfynk ikt/.
1^1^2004 s'A 30^9^2010 d"okB j'Jh
w"s bJh phHvhHghHUH pbke dk Bkw fbfynk
ikt/.
1^10^2010 s'A pkd j'Jh w"s bJh
ghHn?uH;hH$ ;hHn?uH;hH dk Bkw fbfynk
ikt/
(B'NL i/eo b/N nzdoki j? sK
EkDk$phHvhHghHU pbke$ghHn?uH;hH dk Bkw
;kb nB[;ko fbfynk ikt/
i/eo w"s ;afjoh y/so ftZu j'Jh j? sK
Bro fBrw$e';b$Bro gzukfJs dk Bkw
12. ;oNhfce/N dh fezBhnK ekghnK b'VhdhnK
jB.(frDsh)
13. d;skt/ia i' Bkb BZEh eoB/ jB. e'Jh Bjh

14. fpB?eko d/ j;skyo$ nzr{m/ dk fB;akB

dcsoh tos'A bJh

1. gqkgsh o;hd Bzpo 2. fwsh

3. ;/tk d/D dh fwsh 4. ch;$c?;hbhN/;aB ch; 15$^WH (fJZe ekgh
ukoi i/eo e'Jh j? fJZe ;kb bJh) (tkX{ ;kbK
d/ foekov B{z bGD bJh 5
o[gJ/ gqsh ;kb ns/ tkX{
ekghnK bJh 10 o[gJ/ gqsh
ekgh)
5. nfXekos nfXekoh dk Bkw nZj[dk 6.
7. ;EkB nfXekos$gqkgs eosk
8.
nfXekoh d/ d;sys
.
(gqkgsh o;hd)
1. gqkgsh o;hd Bzpo 2. fwsh
3. ;/tk d/D dh fwsh
4. ch;$ c?;hbhN/;aB, ukoi i/eo e'Jh j?.
5. ;/tk i' wzrh j?. w"s ;oNhfce/N ikoh eokT[Dk
6H BZEh d;skt/i fBZb
6(T) nfXekos nfXekoh dk Bkw (n) nj[Zdk
(J) ;EkB (;) nfXekos nfXekoh
d/ d;sys

;w/ f;o ;/tk gqkgs eoBk s[jkvk nfXeko j?.