OFFICE

OF THE PRESIDENT
CIVIL REGISTRATION SERVICES

APPLICATION FOR A BIRTH CERTIFICATE CBC-8PSJ8Z8

FORM B4 FEE: 180 DATE: SUN 16 APRIL 2023

TO BE COMPLETED IN CAPITAL LETTERS FOR OFFICIAL USE ONLY

TYPE OF APPLICATION NEW ENTRY NUMBER

COUNTY OF BIRTH NAIROBI APPLICATION NUMBER

EXACT PLACE OF BIRTH MAMA LUCY KIBAKI PRINT DATE

NAME OF CHILD DERICK AMUYUNZU AGESA NAME OF REGISTERING OFFICER

CHILD ABOVE 18? NO RECORD CHECK BY

DATE OF BIRTH 08-09-2018 ASSESSED BY

SEX OF THE CHILD MALE APPROVED BY

ENTRY OR NOTIFICATION NUMBER

DETAILS OF FATHER AVAILABLE? YES

NAME OF THE FATHER AGGREY AGESA KILIRU

ID NUMBER OF THE FATHER 20836696

DETAILS OF MOTHER AVAILABLE? YES

NAME OF THE MOTHER VIVIAN SHIVULU MUDAMBI

ID NUMBER OF THE MOTHER 23561530

NAME OF THE GUARDIAN

ID NUMBER OF THE GUARDIAN

ADDRESS OF THE APPLICANT MUKURU KWA NJENGA

SIGNATURE

APPLICANTS NAME AGGREY AGESA KILIRU TELEPHONE NO +254720728291

DATE PRESENTED SUN 16 APRIL 2023 PICK UP LOCATION ACK BISHOP