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Narne ~~!~~~~_
residing at __~2(tyt.__g9J),~g~__SJ!!J._~_~Q;l~p-,~rg,_R~~~_
Date of birthJ~!.~~iJ.~_Q.~Date of order of adrnission __?1.2_~~~.?_~_
Date certificate issued c!~J..:L?)'..,__!~.?.!L by the
__Q~~_~_P~~_~~Court at ~~~~1~~~~,_~~~~~_
Petition No.~~~~_
AI ·R·. N .A-3leneglstratlOno.---- -~-9S3 __
--~-----------------------------,.L (~Plete and true signat e of holder).