a be accomplished in quadruplicata) REMARKS/ANNOTATnON

Municipal Fortn No. 102

(Ravised January 1934)
Republic of the Philippines
OFFICE OF THE CIVIL REGISTRAR GENERAL
CERTIFICATE OF LIVE BIRTH
togibly. Use ink ur typowriler
(Fl out complelely, a c c u r alely and
, bD a
Place X batorotfio appiopi ate aOa we o

Sur Registry No
Province uanao Del
City/Municipality Marantao
DCRG USE ONLY
1. NAME (First) (Middle) (Last) ukaton Boorence No
NORA IMAH LUMNA MACATO-ON
2 SEX 3. DATE OF BIRTH (day) (manth) (year)
X June 1966
Malo 2 Female 25 TO BE FILLED UP AT THE
OFFICE OF THE CVIL
C4. PLACE OF (Name of Haspital/Clinic/nstitution/ (City/Municipality) (Province) REGISTRAR
BIRTH2295 House No., Street, Barangay)
Lumbac Inud ara, Marantao, Lanao Del Sur
5a. TYPE OF BIRTH b.F MULTIPLE BIRTH, CHILD WAS
D X 1 Singo 2 Twin First - 2 Second

- 3 Tiplet, etc. 3 Others, Specify

C. BIRTH CRDER (live births and fetal deaths d. WEIGHT AT BIRTH
including this delivery)
Pirst(tirst,cecond,third, etc.) 6.51bs. grams
6. MAIDEN (First) (Mid die) (Last)
NAME
DAMA BUCUA MACATO-ON
7. CITIZENSHIP 8. RELIGION Telam
Mus, Pilip ino
O|92a. Total number of b. No.ofchildren still C. No.of children
children born tiving including born alivo
but o
H alive thisbirth: are now d e a d : -

E10. OCCUPATION 1. Age at the time

of this birth:
Ho usewife 28
years
12. RESIDENCE (Houso No., Street, Barangay) (City/Municipality) (Province)
2295 Lumbac Inud ar an, Marantao, Lanao Del Sur
13. NAME (First) (Middle) (Last)
LUMNA BAGAMBANG CORNELL
14. CITIZENSHIP 15. RELIGION Islam

16. OCCUPATION
Mus, Filipino
17. Age at the timo

Carpenter ofthis birtn: 32 70

yoars
18. DATE AND PLACE OF MARRIAGE OF PARENTS ( not maried, accomplih Atrn.davit of
Acknawladgment/Admisaion of Paternity atthe back)

Jan.27, 1948 at Inudaran,Marantao,Lanao Del Sur 76

19a. ATTENDANT
Phyoician
X4 HIlot (Traditional Midwife)
2 Nurse 3 Midwifte
Others (Specity)
19b. CERTIFICATION OF BIRTH
ihereby certify that I attended the birth of tho child who was born alivo at 00 ano'lock
am/pm on the date stated aove

Signature
Name in Printungan Marilan
Address
Caw ayan Marantao
87
Title or Position 1LLt Datode 23,1966
20. INFORMANT

Signature -
Addressnudaran Marantao
Name in Print na Cornell
Ratetionchip to the childDaughte r
DatoJune23, 1966
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF 93
THE CIVIL REGISTRAR
Signature
Name in Print4 1ca GútoC Signatura
Title or Namein Pint-S PAt0E JAGOLUBA,
Dato
Positiong une 23,1966 Titleor Positio E E RSGETT
Date

7IAN
or births before 3 August 1988/on or after 3 August 1998

AFTDAVIT OF ACKNOWIEDGMENT'ADMISSION OF PATERNITY

Parents/parent
We of the child mentioned in this Certificate of and
Lie Birth, do hereby solemanlysar that he
nyformation contaned herein are true and correct to the best of our/my knowledge and beluf

(Signature of Father) (Signature of Mother)

Community Tax No. Community Tax No.

Date Issued Date Issued
Place Issued Place Issued

SUBSCRIBED AND SwORN to before me this day of_

, Philippines.

(Signature of Administering Officer)

Title/Designation)

(Name in Print)
(Address)
Not applicabte for births betore 27 February 1931

AFFIDAVIT FOR DELAYED REGISTRATION OF BIRTH

(Ether the person hinmself if 18 years old or over, or father/mother/guardian may accomplish this affidavit)

of legal age, single/married

and with residence and postal address
at
after having been duly sworn to in accordance with law, do hereby depose and say:

1 That Iam the applicant for the delayed registration of my birth/of the birth o f

2 That I/he/she was born on_

3 That T/he/she was attended at birth by who resides at
Lauy-
4 That I/he/she is a citizen of
5. That my/his/her parents were married on

n o t married but was acknowledge by my/his/her father whose

name s

6 That the reason for the delay in registering my/his/her birth was due to-

7. That a copy of my/his/her birth certificate is needed for the purpose of.

L(For the applicant only) That I am married to

(For the father/mother/guardian) ThatI am the of the said
person.

(Signbture of Affiant)

Community Tax No. 213539

Date Issued
Place Issued.

SUBSCRIBED AND SWORN to before me

thisLday of
, Philippines.
N

(Signaturo of Administering Oficer) 7Rosignation)

NCD. BACULUueia
dress