‘Municipal Form No. 102 (To be accomplished in quadruplicate using Back in) (Revised January 2007) Republic of the Philippines OFFICE OF THE CIVIL REGISTRAR GENERAL CERTIFICATE OF LIVE BIRTH ~ Registry No. Province __ — City/Municipality a 1. NAME Fay ‘ley Test | 2. SEX (Male/Female) 3. DATE OF (Day) (Month) (Year) - c iRTH H piace oF [Name of Hos inic/Instituton’ (City’Municipalityy (Province) 1| “aire louse No. Sf Barangay) 4 - p [ss Weoranne @ IFMULTPLEBIRTH CHILD WAS | 50 BIRTH ORDER oom snsum [6 WEIGHTATBIRTH {Grate Tin Tete) (Prt Second Th.) ees a a | grams 7. MAIDEN Fre (wise) as) NAME M | eomeensa ‘D RELIGIONRELIGIOUS SECT Ss 1H| 100 Toul uréer of | 10D. of citon ast_]T0= Neo dion Go, OCCUPATON TZ.AGE dive we te E children born ave | — living including this birth abn ere new deed ‘bith (completed years R} 7a RESIDENCE House No. St, Barangay) —(CigMunicpaliy) —*(Provinoe)=SC*«CCoumy)sSCSttStC*~*~«* FE 14, NAME (First) (Middle) (Last) A yecmzensne ] 76 RELIGIONRELIGIOUSSECT 57, OCOUPATION 18. AGE abe ire dhe 7 ‘at (colt years) H a 418, RESIDENCE (House No., St, Barangay) [CiyiManicipaly) (Province) (Courty) IMARRIAGE OF PARENTS (t not mamied, aocomplsh Aftdavit of Acknowledgement/Admission of Paternity atthe back) i200.DATE (Month) (Day) (Year) | 20B.PLACE (Cly/ Municipaly) (Province) (Country) lata. ATTENDANT - _1 physcin 2 Nuso___8 Mito. __4 lot (Tradona Birth Atondant) _5_ Others (Spec) lob. CERTIFICATION OF ATTENDANTATBIRTH(Phsican, Nurse, Mel, radon Br\AtorarHt kc) | hereby carty that | attended the bith ofthe child who was born ave at amipm_on the dae of Bh specified above. Signature Are Name in Pit Tite or Postion Date 7 22. CERTIFICATION OF INFORMANT 23. PREPAREDY | hereby certify that all information supplied are true and correct to my ann knowledge and belie. Signature Signature - Name in Print | ame in Print Relationship tothe Chi [ retior eaen Address ote _ Date 24, RECEIVED BY 26 REGISTERED BY THE CIVIL REGISTRAR Signature - | Signature Name in Print Name in Print Tile or Position Tile or Posten Date Date . REMARKS/ANNOTATIONS (For LCRO/OCRG Use Only) 70 BE FILLED-UP AT THE OFFICE OF THE CIVIL REGISTRAR ao 0 6 6 OT 10AFFIDAVIT OF ACKNOWLEDGMENTI/ADMISSION OF PATERNITY (For bits before 3 August 1988) (For bits ono afer 3 August 1066) and ‘ of legal age, amlare the natural mother andlor father of who was born on at | am J We are executing this affidavit tc attest to the truthfulness of the foregoing statements and for purposes of acknowledging my‘our child ‘ignature Over Printed Name of Father) ‘Barature Over Printed Name of Mother) SUBSCRIBED AND SWORN to before me this dayof_ by and ‘who exhibited to me (his/her) Community Tax Cert. No. issued on at ‘Signature of the Administering OMicar Poslon] Tite Designation Name PRAT Taare AFFIDAVIT FOR DELAYED REGISTRATION OF BIRTH (To be accomplished by the hospitalicinic administrator, father, mother, or guardian cr the person himself 18 years old or over.) 1 . of legal age, single/married/divorced/widow/widower, with Fesidence and postal address at. after having been duly sworn in accordance with law, do hereby depose and say: 1. That lam the applicant for the delayed registration of: my birth in the birth of 2. That lme/she was attended at birth by 3. That | am/he/she is a citizen of 4. That my/hisiher parents were ‘married on ‘not married but Une/she was ecknowedgedinat acknowledged by my/hisher father whose name is 5. That the reason for the delay in registering my/hisiher birth was 6. (Forte applicant only) That | am married to (ifthe applicant is other than the document owner) That | am the Of the said person. 7. That am executing this affidavit to attest to the truthfulness ofthe foregoing statements for all legal intents and purposes. In truth whereof, | have affixed my signature below this day of _at » Philippines. (Signature Over Pri SUBSCRIBED AND SWORN 1o before me this day of i at + Philippines, affiant wio exhibited to me his Community Tax Cert issued on at