Professional Documents
Culture Documents
LLKKLKL
LLKKLKL
102
(Revised January 1993)
REMARKS/ANNOTATION
Province _________________________________________
City/Municipality ___________________________________
1. NAME
(First)
Registry No.
(Middle)
2. SEX
(Last)
3. DATE OF BIRTH
(day)
(month) (year)
C
H
I
L
D
4. PLACE OF
BIRTH
(Name of Hospital/Clinic/Institution/
House No., Street, Barangay)
(City/Municipality)
41
b.
_____ 1 Single
______ 2 Twin
______ 3 Triplet. Etc.
6. MAIDEN
NAME
7.
CITIZENSHIP
9a.
Total number of
children born
alive: _________
(Middle)
13. NAME
(First)
56
11.
50
c. No. of children
(Middle)
61
(City/Municipality)
(Province)
62
64
68
69
70
72
(Last)
14. CITIZENSHIP
16.
49
(Last)
8. RELIGION
b.
48
________________ grams
10. OCCUPATION
12. RESIDENCE
F
A
T
H
E
R
(First)
______ 2 Second
Others, Specify _____________
d. WEIGHT AT BIRTH
M
O
T
H
E
R
TO BE FILLED UP AT THE
OFFICE OF THE CIVIL
REGISTRAR
(Province)
15. RELIGION
OCCUPATION
17.
74
18. DATE AND PLACE OF MARRIAGE OF PARENTS (If not married, accomplish Affidavit of
76
79
19a. ATTENDANT
_____1 Physician
______ 2 Nurse
______ 3 Midwife
_____4 Hilot (traditional Midwife)
______ 5 Others (Specify)
_______________________________________________________________________________________________
81
Address ______________________________
_____________________________________
86
88
20. INFORMANT
Signature ______________________________
Address ______________________________
_____________________________________
93
21. PREPARED BY
Signature ______________________________
Signature _____________________________
94
87
91
_______________________________
(Signature of Mother)
_______________________________________
(Title/Designation)
___________________________________________
(Address)
_________________________________________
(Signature of Affiant)
________________________________________
(Signature of Administering Officer)
_________________________________________________
(Name in Print)
_____________________________________
(Title/Designation)
______________________________________________
(Address)