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Translation

Form Thor. Ror. 1, Part 1


CERTIFICATE OF BIRTH

Registration Office Ratchathewi District 0 1


Personal No. 1-1037-02505-29-3
1.1 Name : Onvanya Surname : Phuttharak 1.2 Sex : Female 1.3 Nationality : Thai

1. 1.4 Date of birth : Day / Month / Year Time 18.00 hrs. Corresponding to : Waxing Moon : Month : 1 Year :
27 December 1997 Waning Moon : 13
The 1.5 Place of birth : House No., Village No., Lane, Alley, Road, Sub-district/Sub-area, District/Area, Province :
New Ramathibodee general hospital 270 Rama IX Rd. Phayathai, Ratchathewi District, Bangkok, Thailand
Born 1.6 Being the child No. : 1 1.7 Person Performing Delivery : ○ Self delivery ○ Midwife ○ Other:……..……. 1.8 Weight at birth :
○ Nurse ○ Obstetrician ○ Physician 3,720
1.9 Name added to House Registration No., Village No., Lane, Alley, Road, Sub-district/Sub-area, District/Area, Province : gms.
10 Moo 77 Phayathai Rd. Ratchathewi District, Bangkok, Thailand
1.10 Code number of house where name is added : 1037-001479-1
2. 2.1 Name : Orawan Surname : Somboune 2.2 Personal No.
Mother 2.3 Age : 34 Years. 2.4 Nationality 2.5 Born in province : Country :
Ø Thai ○ Other:……………… Bangkok Thailand
2.6 Residence : House No., Village No., Alley, Road, Sub-district/Sub-area, District/Area, Province, Country :
8/31Burapa 7, Moo 5, Si-kan, Donmuang, Bangkok, Thailand
3. 3.1 Name : Chusak Surname : Phuttharak 3.2 Personal No. 3101700383756
Father 3.3 Age : 32 years. 3.4 Nationality : 3.5 Born in province : Country
Ø Thai ○ Other:………………… Sa sa ket Thailand
3.6 Residence : House No., Village No., Lane, Alley, Road, Sub-district/Sub-area, District/Area, Province, Country :
○ Same as mother's ○ Different
4. 4.1 Name : Prajuab Surname : Pongpala 4.2 Personal No. 4.3 Age : years.
Person 4.4 Residence : House No., Village No., Lane, Alley, Road, Sub-district/Sub-area, District/Area, Province :
Notifying 270 Rama IX Rd. Phayathai, Ratchathewi District, Bangkok, Thailand
Birth 4.5 Relationship to the newborn ○ Head of Household ○ Father Ø Person performing delivery
○ Relative ○ Mother ○ Officer ○ Other :…………………………..
4.6 Document Certifying Birth : 4.7 Document Acknowledging Birth : 4.8 Signature of notifying person :
Ø Yes ○ No ○ Yes Ø No
Certified correct translation
Signature of Registrar Acknowledging Birth
(Signed)………- illegible-…… …………………………………..
(Mrs.Sirirphan Sriratsatian) (Chusak Phuttharak)
Registrar………… Ratchathewi District …………………. Translator
Date : …………December 29, 1997……………………….