No.

1112
t99J)
- (To be -mpllsl,ed in quaJryplk:ale)
-- REMARKS/ANNOTATION
Page 1 of 1, 1 CO,:,,
(Copy !of OCRG)

Republic of the Phlllpplll9$

OFACE OF 11-!E CIVIL REGISTRAR GENERAL
CERTIFICATE OF LIVE BIRTH
(~ DUI oo,nplotely, __,...iy .itd IOgibly. u.. Ink or ty.....-,ito,,
Placll X ..,_, In _,. 2, r.t.. 5b .... 11a.)

!. Cl'l'X

t. NAME (Fi'll) (Mlddi.) (Lui) l'w OCIIG USE ONLY: - •

.JAM p ~ ~ ,• ..,.. •.

rx
BRIAII 851118
2. 3. DATE OF BIRTH p n; :,l\9f.-5Fei,/-S--!
-- I - - 2 Fe11llt tOBtftlU!OUPATTJj£ .
C 4. PlACE OF (Nameof~n.1/Cllnlc/lnSlltuGon/ (Ctty/Munldpality} (Province) OFflCI! Of/ ntt CIVIi.
M.GISTRAR,
H BIRTH t,
Houu Ho., 611.. Blr111gay) .
t DIU.. 01.IVL\ S~AMOOA llJ!JBllAL llOSPl'UL. CAYITB OITI CAUi.i 41 ,, _,..,.,

L 58. TYPE OF BIRTH

D .!_ 1 s;ng1e
- b. IF MULTIPLE BIRTH, CHILD W/4S
_ _ 2 T'win _ , Flrat _ _ z S.concl EtYa f. l-J19J; _lf'I

.1rro1,
- - 3 TriOlet. ete. - - 3 Olhe~ Sp~·
4J
e. BIRTH.ORDER (ll.. blrth1 and fetal dt1th1 d. WEIGHT AT BIRTH
S~ . lnclulllng 1h11 delivery) on
21•7.1 -r6;
[lI
...
(6m,aecond,thkd,eto.) lll1lffll
I
f="-:&I) ('Idelle) (Lut} . ,

l.lW)ftClA !81'Alll:>I JJIU [!

7.- ClniENSHIP 6. RELIGION
ru.. a..o. 51 •
TOIIII number of
_,,., .,, -
,. cliildt9n bort" -
b. No. ofehlldren $111
IJving Including
lhlablrtll: _ _$_
c. No. of dllldren
born alive but G
are now dead: _ _ __
1:-J 1:-- h EJ
1
r

. OCCUPATION 11. I.gt at the tlmo

U..aldl'e olthlablrlh: .,.
. --year,
~RESIDENCE l'-to11te No~ SlrHt, Batangay) (OtyjMunlelpaijly) (Provine.)
12 ..
Jmtw Sczli9l.
f1rU)
-
(~)
T
(I.all)
k:I-ST .k... . l~
.. ......
---~-~o~taadzn-~- -----,..•-1e0---• - - --~-~t:r-.-- - - -
,

oa - u=
. <lTIZENSHtP
Ill. 15. FIE'Jl~.N
q][JJ
,- -
OCCUPATION 17. Age at the lime
' ofthla blflh:_ .
....,_~• 70 7Z

,..._ "".18!.: bAleJ\ND RACE Of'MAARIAGE OF PARENTS (If Mt married, acoompfiih Affidavit of Eli]
"""'; ~/Admisslel\Gfl'Uarllltyalthabaclt.)
~.;, "' SJP'tf.l(BJR 21,__-1991• MAl'IDAUJYO»G Mi!.1'M
i 'i~-'4-tl'ENOANT .
;.,, -x . J_ I ' l l ~ _ _ 2 Nut .. _ 3 Mldwdt
,., ""' ::!:, -~~~Aldwit,) _ 5 Otti.rt (Specify)

:~ =19b. CERTIFICAlJON OF BIRTH -

~--
11
"' ""'
,-c - ~9rttt.
lh"en!br ce.ni(y't-.ail J~ N tlitlll of Ille d)ild who -
.... (!&lt•111t11-
_.,.. _;..
born dlut___ 1,.,0"-"&~
.,,,10.___ o'c:klclr I=> 1·1 I')le I'll 1

_· Nan)li,,
- .. IT
t 'l'illt OJ PQsHion"
20. INFORMANT UJ CZl
~'rek'rrto :temol, b0::a,
Dato S,n,t91,bt:r lb, J9~6 -
I tit 1~11 i

i 03176--10-005CEM--00146-B1001
JEiTP0881UIMAGE BReN •
CARMELITA N. E T
1111110IIIIIDIUl 1111111111111111111111111111111
T~17&0060014609112008001
02105-A96SF06-5
(':,'Jn";11tl.,,' Administrator and Civil Registrw
Lt.. , ,p (·y , j National Statistics Office
71