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01-4943944-1
[Bar code]
DOMINICAN REPUBLIC
FORM OC-11
[Holographic Seal reading: CENTRAL ELECTORAL BOARD Event No.
JCE] NATIONAL CIVIL STATUS REGISTRY 001-01-2009-01-00013103
EXTRACT OF BIRTH CERTIFICATE Mun. O.C. Year Reg. No.
(Art. 99 Law 659 of 7-17-1944)
WE CERTIFY: That there is on file with this Civil Status Office of the 1ST CIRCUMSCRIPTION NATIONAL
DISTRICT, a record which was entered on the eighth day in the month of July nineteen ninety two
(07/08/1992), in Register Book of BIRTHS No. 00659, TIMELY DECLARATION, Folio No. 0153, Act No.
02153, Year 1992 belonging to:
Of the MASCULINE sex, born in CLINICA SAN RAFAEL on the nineteenth day of the month of June of the
year nineteen ninety two (06/19/1992).
FATHER: PEREZ EUREN, LUIS ANDRES, country of nationality Dominican Republic, identity card
No.039466-037
MOTHER: ROA MONTERO, MARCIA JOSELYNE, country of nationality Dominican Republic, identity
card No.327859-001
[Signature]
CARMEN ANGELICA MOTA BRITO [Bar code]
Civil Status Officer