Form B4

OFFICE OF THE PRESIDENT

DEPARTMENT OF CIVIL REGISTRATION
APPLICATION FOR A BIRTH CERTIFICATE

Date:23 August
Application No: CAECB-AACHWM7 CA: 2022

Fee:Â180 Invoice No: Cashier's Sign

TO BE COMPLETED IN CAPITAL LETTERS ENTRY NO
APPLICATION
COUNTY OF BIRTH NAIROBI
NUMBER
NAME OF
SUB COUNTY OF BIRTH NAIROBI REGISTERING
OFFICER

NOTIFICATION NO 5113925

DATE OF
EXACT PLACE OF BIRTH KAYOLE II CLINIC
REGISTRATION
RECORD
NAME OF CHILD LEONADESS CHRISTOPHER SEMENI
CHECKED BY

 DATE CHECKED

DATE OF BIRTH 15 JUNE 2018 SIGNATURE

SEX OF CHILD MALE FEE PAID

NAME OF PARENT RENFREW HAMISI SEMENI ASSESSED BY

ID NUMBER OF PARENT 31363423 DATE ASSESSED

NAME OF OTHER PARENT SIGNATURE

ID NO OF OTHER PARENT APPROVED BY

NAME AND ADDRESS OF APPLICANT RENFREW HAMISI SEMENI DATE APPROVED

TELEPHONE NO. +254705193280 SIGNATURE .

SIGNATURE

APPLICANTS NAME RENFREW HAMISI SEMENI

CHILD'S NAME LEONADESS CHRISTOPHER SEMENI DATE OF BIRTH 15 JUNE 2018
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DATE PRESENTED 23 AUGUST 2022 HUDUMA GPO
LOCATION