M & J Western Regional Institute of Opthalmology (Eye Hospital) ‘CIVIL HOSPITAL, AHMEDABAD-16, Form-IV Disability Certificate __ + “(in case other than those mentioned in Forms Il and Ill) (MAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE) a (See rule-4) | | EE 2) GT a eae aie COURT PURPOSE artncste No. ve 11843 83 Date: 70/3 [2044 PTANe.:_ 207 This is to centity that | have caretully examined Shri/Smt/Kum. Pave. Rushatore # Son/wife/deugnter of Shri Shawkle«4 pete ot Birth copmmwyy)_ 21 0& | (996 Age_<)|__ years, male/female Registration No._2© 7% _ Permanent resident af House No. 9.3 WardViliage/Street 1 ! } | Post Office A bad pistice_#! bad _ aoe whose ron 3 aph is affixed above, and am satisfied that he/she isa case ot_4.00°]- disability. His/her e tent of percentage physical impairment/disability has been evaluated as per guidelines (to be specified and is shown against the relevant disability in the tatsel below ; Sr. | Disability Affected part! Di is Permanent No. of Body as ea. | mental disability (in %) X | Leeometorsisabiity | @ CRED Disc 2 | LowVision # 2 Dye fa 4 EMt) apo! 3 | Blindness Both Eyes ic : 1% [Hearing impairement| & K |Mentatrotertation | KK |Mentotitiness lx (Please strike out the disabilities which are not applicable). 2. The above condition is progessive/ non progressivel likely to Improve/not likely to improve. 3, Reassessment of disability is | () notnocessary, Or (ii) is recommended ! after _ years months, and therefore this certificate shall be valid tilt (oDMaMryy) 2 © 85. Laman armailegs - e.g. Single eye / both eyes le: .g. Lefi/Rightboth earswikis 8 ape ability fara. gov inyportl wi? Certiicsto No: 2agz8 ‘Thu ito cory hat | rave oatetily sxamanedt ShovSmt um dest BAND / Neal babubha! Desai sontaeldsuphter of Shri eueynues Date of Bem (OMIM YYYY) IBCIZ/IB87 Age 30-Yeer(a) Femme Regisiraion No. RAW 7/OTIBT48S [sc] omar, | Aifected pert of Bey Diegnosts | Pecmanara physical Ne Impairment! mereal ‘iabity in 8) i 1 | Bieinese Boo Eye 1) BE-Wierephitainos | 150 (One unreal) ri ier Comee wt | L ee sical) 2 The above condiion ls progressive’ nom ogres They bel na hay © Irprow 3 Reassesemant of disabilly i: Not Necessary ‘The applicant hes submitted the folowing document as proot of wesldence:. [Nature of Document Date ofissus | Detativ of auithorityinauing coviioams | | Raton Gar wo, arta sot nae ttt Geter tated store ae Pus oh bof ay treo ae belt ferther sate 8 |bave-not avated ary other dissbaty cadiicain from tha health depariment. fn ease any inaccuracy fa “ateciodon My rt, hal be abe to frets ot Sy bias derived wed cer action as gerne Signatures Thoms impeesaion bn WhOSE Fowour dissbiliy sametite \wissved Now: TRIGA nes ere pune he Gnome of ra vido atten maar 6.0; BOBE), ad he Ste Desember 1908 _, oan Gee ante nara 1 Nest Rush ‘Shem (ons41 ya ; ————— cee ieee NOT FOR M.L.C. OR COURT USE. No. VH/ Certi..“ a Re. et ok Sir Pratap General Hospital O.P.D. NO. i Himatnagar. Dist. Sabarkantha Date: |f /2- /2004-2005 Date: \6 #2 /2004— , . er VISUALLY HANDICAPPED CERTIFICATE , fied i Cote Elev), UB rvs De estercees Vig. nti mas Ss _is examined by me at this hospital for Visually Handicapped. [1] Disease........[2C3....25 [2] Defermity & Disability / Handicapped ... Is] Pareantags 2 heh oer eA 4M & J Western Regional Institute of Opthalmology (Eye Hospital) CIVIL HOSPITAL, AHMEDABAD-16. Form-IV Legreceadp Disability Certificate r than those mentioned in Forms II and Il!) (See rule 4) VALID FOR ANY COURT PURPOSE SED. M&dJ Certificate No: C{ Mees Date: 4 1é [eos Civil Hospice, Aiimecavad-s80 016 PTA No. 1934) [2olg This is to certify that | have carefully examined Shri/Gert/Ku | - BRAD Sort/wité/daughter of shi Vevey rua Bate abi rth(DD /MM/YY) j= y= Pig. Age £4 ae m ere Registration No. / G34, /20/ ¢ Permanent resident g3 Ds? { of House No. OT yaiaMiiage/sret ON SHARE Nim AR 2 NO. BEARER feu) Post Office \/ ATV A District ANK\EDAR AN State_ (yo utARAT ten Ae is affixed above, and am satisfied that he/she is a case of ( (6 ) Viz pt disability. His/her e tent of percentage physical impairment/disability has been evaluated as per guidelines (to be specified and is shown against the relevant disability in the table below: Sr. | Disability No. feecometordiscbiiy/@ | fare |) Waren SS Permanent Physicai impairment/ mental disability (in %) Affected part of Body Diagnosis her Hi (Please strike out the disabilities which are not applicable). 2. The above condilion is progressive/non-progressive/ likely to improve/ not likely to improve. 3, Reassessment of disbility is: (i) not necessary, Or (ii) is recommended /after__years__—— months, and therefore this certificate shall be valid till (DD/MM/ YY) £ Lof) @ -e.g. Left/Right/both arms/legs # - e.g. Single eye/both eyes ¢ - e.g. left/Right/bhoth earsa eH ae seer, ee ur mms ied SU. a ee ¥ re Se A LA. eH Pome Sere CT havea: oH Aenea ROL RT 4 cee OL RAT See Sree LAT, ‘Se re mien mS a it ee ee SS ner SS Pe Semen SL a neem be Ser EE a SS eee oe 0 — = A: aay ea ol PERS fe eee are a i: see ee ey oe em By ere | eee rhe ey: Mes oe a ———aaiees — - Rees tenet te eer ae eee een ee a 8 i gene fl Selec ostanieeeeee fa SE Sa ee en Sa SR mm Hs m8M & J Western Regional Institute of Opthalmology (Eye Hospital) ‘CIVIL HOSPITAL, AHMEDABAD-16, Form-IV Disability Certificate __ + “(in case other than those mentioned in Forms Il and Ill) (MAME AND ADDRESS OF THE MEDICAL AUTHORITY ISSUING THE CERTIFICATE) a (See rule-4) | | EE 2) GT a eae aie COURT PURPOSE artncste No. ve 11843 83 Date: 70/3 [2044 PTANe.:_ 207 This is to centity that | have caretully examined Shri/Smt/Kum. Pave. Rushatore # Son/wife/deugnter of Shri Shawkle«4 pete ot Birth copmmwyy)_ 21 0& | (996 Age_<)|__ years, male/female Registration No._2© 7% _ Permanent resident af House No. 9.3 WardViliage/Street 1 ! } | Post Office A bad pistice_#! bad _ aoe whose ron 3 aph is affixed above, and am satisfied that he/she isa case ot_4.00°]- disability. His/her e tent of percentage physical impairment/disability has been evaluated as per guidelines (to be specified and is shown against the relevant disability in the tatsel below ; Sr. | Disability Affected part! Di is Permanent No. of Body as ea. | mental disability (in %) X | Leeometorsisabiity | @ CRED Disc 2 | LowVision # 2 Dye fa 4 EMt) apo! 3 | Blindness Both Eyes ic : 1% [Hearing impairement| & K |Mentatrotertation | KK |Mentotitiness lx (Please strike out the disabilities which are not applicable). 2. The above condition is progessive/ non progressivel likely to Improve/not likely to improve. 3, Reassessment of disability is | () notnocessary, Or (ii) is recommended ! after _ years months, and therefore this certificate shall be valid tilt (oDMaMryy) 2 © 85. Laman armailegs - e.g. Single eye / both eyes le: .g. Lefi/Rightboth earsg | S9er/le ws Department of Empowerment of Persons with Disabilities, Ministry of Social Justice and Empowerment, Government of India ee Disability Certificate Rahul Catan oS Authority, Patan, Gujarat 1 NOUS a Optinalmic as Ma 19930006819 Date: 26/03/2018 This is to certity that We have carefully examined Kum. Darshanaben Hasmukhbhai Prajapati Daughter of Shri Hasmukhbhai Date of Birth 23/06/1993 Age 24 Year(s) Female, Registration No. 2403/00000/1802/0900356 resident of House No. At-patan,kapasiya Vada Same, Ta-patan,dist-patan, Pin Code No,-384265 - 384265 Sub District Patan District Patan State / UTs Gujarat Whose photograph is affixed above, and I/We satisfied that: Certificate Nov: Gjo3: {Al She isa case of Blindness (B) The diagnosis in her case is NOPL, RE - PTHYSICAL EYE, LE-CORNEAL OPACIETY WITH LOST EYE (C) She has 100%(in figure) One hundred percent(in words) Permanent in relation to her (part of body) as per guidelines (to be specified). | | The applicant have been submitted the following document(s) as proof of residence | Nature of Document(s); Ration Card eee * Signature / Thumb impression of the Person With Disability Pryde anieY ndhi a of natified Medical Auth se ay Assistant Rd soot Optic GMERS Medical College roe Dharout - Patan Issuing Medical Authority, Patan, Gujarat This Card/Certificate is meant to certify the disability of the person and is not an instrument for ID/Address Proof for any purpose.Sir Pratap General OPO NO, Ou Himatnagor Dist Sabarkartha Date: \¢ 12. (2006-2008, Date: 16 12 roe fae O} pe. Roidento SH. ths UebnZ BENE SEK ssoramredsy meats hosptal fer sat Handicapped. i [1] Disease... 1 erin oh te’ Page | of 2 : ese ieee eee - i {ih cases other than those mentioned in Forms i and oH 7 Pe Geer rect fee mer eee Certificate No.: This is to certify that | hawe Carefully examined i i ane SheiiSrmt-AKum. Glett bees 5.8.6. Hospital & Medica, . wiege sonfwitecaughter of Shri Gelguie Vadodara, e Date of Birth (DD /MM I YYYY) 22/04/1901 Age 24 Year(s) Female Registration No. VDRI15/01082460 Address g-5,krishna darshan flats, ne.nutan schoo! new sama ruad, Vadodara Mun. Corpor, VADODAR: VADODARA | whose photograph is aHixed above, and am satisfied that heshe & a case of Blindness disability Histher extent of permanent physical impairmentdisabilidy has been evaluated as per guidalineas(to be specified), and shown against the relevant disability in the table belaw:- Permanent physical Body impairment f mental disability (in %) 100 (One Hundred ) 2. The above condition is progressives non-progressivel tkely to improve! not likely ta improwe 3. Reassessment of disability ig Nol Necessary 4. The applicant has submitted the following document as preef of residence:- Mature of Document Certificate 1) Right eye total leucomatous comeal Opacity Left eye phihysis bulbi Undertaking: | hereby declare that all the personal information Staled above are true to the best of my krowledge and belieh Luther state that | have not availed any other disability certificate from the health department, if in case. any Hdelected on my part, | shail be liable to forfeiture of any benafits derived and other aeties os he re! Thumb impression in sealies pas., whose favour a certificate Wiis GHR typ) ss ' Opitteetrandses! icpartnient is Ssued 5.5 Choqetemigrediedica! College {Countersignature and seal of the CMGiMVedical Superintendent/Head of Government Hospital 6 Sige the certificate is issued by a medical authority wha is not a government servant (with seat) hitp:/www.ability. gujarat.gow.in/portal/wels? 1ova/2015M & J Western Regional Institute of Opthalmology (Eye Hospital) ‘CIVIL HOSPITAL AHMEDABAD 16. Disab Cardeatn Air cakes other Ihe thoes reantisned in Poors liandisit AMD ADORE GS OF THE MEDICA AUTHONUTY (SUING THe (Genraied) sy MOT VAUD FOR ANY COURT PURPORE + mh an a Lr All A: 162 Coe! oy pete 2 RO ‘Then ine cory Pan Pave corel meri Govind Mem CSW Selynit ewe ah Sorvigihetigyghtr of Gitei_!sT eure ee Age__2 yon, resiiemate Regione, NE ermine rites! Yoee No, WEES Mave/Vogettrent_ SUE Ith Men ee! cca sAeuieegun Dini _fMraribnd Fein Gh Samo whoa. prntergeaph in mies above, and ore sotbed thet tate in acase el E _inaisity Histoer mnterd of parcemiage physinal ‘Syceremridimabity haa beer tvbhsinie as par gomtebrem. its bey aeboi od | anclin ahora againat the strand chmabelty in ha unbie besiae [Pb eet cat ou nabs ahs ave rol pcan). 2 Tha abrea conailion i pragriiesetron-pregremivey Bkpy ti orgrive! rol ly fo cere, 14 oo reconnesces: za and bharwinny thet ces Ukiah Wel be vm flaw yy te gor 2-29 Lenrigeon 4 io aie ae 2: og eighth aa =