Manipal Form No, 102 {Tobe accomplished in quadrupicato using back ri) (Revised dans 2007) Republic of the Philppines OFFICE OF THE CIVIL REGISTRAR GENERAL Registry No Province. = aay City/Municipality 1 NAME Tre ‘Miatey Toay 2, SEX Male Fema) "| DATEOF (ay) “Monthy c BIRTH PLACE OF ame 6 Hegre Cinnsttaonr ar ree) | eee apg eivnanispaiiy Frown} L 7 = | S1PeorsieTa ® IF MULTIPLE BIRTH, CHILD WAS | 56 BIRTHOROER oxscniuim » [6 WEIGHTATBIRTH (Seta Tepe ot) (Gra Secon, Tt ke) seyret) grams 7. MAIDEN Fe ‘wdey aa NAME: M . | eormncue @ REUGONRELIGOUS SECT e [| 0s. Tt munber of 700, noo cites sot 08 Ro. of ueron son 77 OOGUPRTION TZ. AGE am te E ‘chiidren born alive | living including this birth (nad re none sieat: ‘bith (cormpleted years) RR) a ReSiOENCE (House No, St. Barangay) (Civunicipaiyy Prowncs) County) ese Fre (ne) Tay A) scmzensaP 16 RELIGIONRELGIOUSSECT {7 OCCUPATION 18. AGE apo tne ott rT ico yo) H . 18. RESIDENCE (House No. Si, Barangay) ‘(Cliyaunicipaty) (Province) (County) MARRIAGE OF PARENTS (i ot arid, scomplsh Aftcaut of Aeknowadgementamaso of Paeiy she back) J. DATE ——(Menth) (Day) (Year) | ZORPLACE (City Municipality) (Provines) (Country) a, ATTENDANT 1 Prysicion 2 Nurse 3 Mitte 4 Hilot Tadtona inh Atendant) 5. Others (Spacty) tb, CERTIFICATION OF ATTENDANT AT BIRTH Physcon Ns Uc, Ton! Bt Atndani, ee) 1 hereby crty that tended te brn of te child who was bom ave at ‘2n/pm_ onthe dato of bith spected above. Signatuve _ Address Nome in Pint = Tie of Posion__late 22. CERTIFICATIONOF INFORMANT ZB. PREPAREDBY I hereby cert that at ifxmalion supplied are tue and correct my own knowledge an be. Signature Signature - ‘Nace in Pri__ — Name in Print _ tT —— Relatonshiotothe Chie <= Te of Postion — at a ig ON 24 RECENEDBY 25 REGISTERED BY THE CNL REGISTRAR Signature = Signature Name in Pint Name in Pit Tie of Postion ie of Potion Date_ _ ate | REMARKS/ANNOTATIONS (For LCROIOGRG Use Only) ‘70 BE FILLED-UP AT THE OFFICE OF THE CIVIL REGISTRAR es 9 4H 3 6 8 19 | |AFFIDAVIT OF ACKNOWLEDGMENT/ADMISSION OF PATERNITY (For bint before 3 August 1988), (Fortis ono afer 3 August 1988) Wie, and of legal age, am/are the natural mother andior father of who was born on. at | am / We are executing this affidavit to attest to the truthfulness of the foregoing statements and for purposes of| ‘acknowledging my/our child (Gionature Over Finied Name of Father) (Gianature Over Printed Namo of Mathar) ‘SUBSCRIBED AND SWORN to before me this day of, hy and who exhibited to me (hisiher) issued on _ at Community Tax Cert. No ignalure of he Admlleteng Ofer Position Til Dasignaiion Namen Pint ndaross AFFIDAVIT FOR DELAYED REGISTRATION OF BIRTH (To be accomplished by the hosptallnc administrator, father, mother, or uardian or the person himself if 18 years old or over) Of legal age, single/marriedidivorcediwidew/widower. with ‘residence and postal address at a ‘after having been duly swom in accordance with law, do hereby depose and say: 41. That | am the applicant for the delayed registration of my birth in on the bith of. who was born in 2. That lhefshe was attended at birth by who resides at ‘That | amvhelshe is a ctzen of ‘That myisMner parents were ‘married on ‘not manied but Ubelshe was acknowedgedinot acknowledged by myfisther father whose name is 5. That the reason for the delay in registering my/hisyher birth was 6 ‘That | am married to (For the applicant only) (ifthe applicant is other than the document owner) That | ar th of the said person, 7. That | am executing this affidavit to attest to the truthfulness of the foregoing statements forall legal intents and purposes. In truth whereof, | have affixed my signature below this. at day of. + Philippines, {Signature Over Printed Name of Affant) SUBSCRIBED AND SWORN to before me this day of at Philippines, affiant who exhibited to me his Community Tax Cert Issued on. at — ‘Signature of the Administering Officer PPositon Tif / Designation