Page 1 of 2, 1 Copy
KATISTtCe
Munkipal Fom No t02 Comolinhed iri aundruplicate Using biack ink
(Revioed January 2O07)
Ropublc of the Philippines
OFFICE OF THE CIVIL REGISTRAR GENERAL
CERTIFICATE OF LIVE BIRTH
Metro Manila Registry No.
Province 2017 1344
City/Municipality Las Piñas City
1. NAM (First) (Middle) (Last)
2. SEX (Male / Female) |3. DATE OF (Day) (Month) (Year)
C Female
BIRTH 20 January 2017
|HpLACE OF Name of Hospital/Cliricjinstitution (City/Municipality) (Province)
BIRTH House No., S., Barangay)
L
Las Piñas General Hospital &Satellite Trauma Center, Las Piñas City
5a. TYPE OF BIRTH 5b. IF MULTIPLE BIRTH. CHILD WAS 5c. BIRTHORDER (Order of ts birth to 6.WEIGHTAT BIRTH
D (Single.Twin, Triplet, etc.) (First, Second, Third, etc. previous lve birhs indudng fetal death)
(First, Second, Third, etc.)
Single Sixth 6.38 lbs.(2.9hrams
7. MAIDEN Finst) (Middle) (Last)
NAME
M
8.CITIZENSHIP 9.RELIGIONRELLGIOUS SECT
Filipino Catholic
12. AGE at the tme of this
u 10a. Total number of 10b. No. of chidren still 100 of chlldren hn
are now dead
|1.0CCUPATION
children born alive living incuding this birth alive birth (completed years)
6 6 Vendor 36
R 13. RESIDENCE (House No., St., Barangay) (Country)
(City/Municipality) (Provnca)
Tabon 2, La Huerta, City of Parañiaque
14. NAME (First) (Middie) (Last)
18. AGE at the ime of this
n15 CTZENSHIP 16. RELIGONRELGIOUS SECT |17.00CUPATION tirth (completed years)
Filipino Catholic Vendor 40
19 RESIDENCE (House No., S., Barangay) (City/Municipality) (Province) (Country)
R Tabon 2, La Huerta, City of Parañaque
MARRIAGE OF PARENTS (f not maried, accompish Afidavit of Acknowledgement/Admission of Patemity at the back.)
20a. DATE (Month) (Day) (Year) 20b. PLACE (City / Municipaity) (Province) (Countyy)
Not Married
21a.ATTENDANT
X 4 Hiot Traditional Birth Attendant)
Physician 2 Nurse 3 Midwife 5 Others (Specify)
21b. CERTIFICATIONOF ATTENDANT AT BIRTH (Physidan, Nurse, Midwie, Traditionat Bith AtlendantHilt,etc.)
I hereby certify that I attended the birth of the child who was bom alive at 9:35 PM avpm on the date of birth specified above.
Signature Address Las Piñas General Hospital &STC
Name in Print
SHERA;LAINE P. NOvo, M.D. Pulang Lupa Las Piñas City
Medat Oficer lI January 23, 2017
Title or Positíon Dat
22 CERTIFICATION OF INFORMANT 23. PREPAREDBY
Ihereby certify that all information supplied are tnue and
correct to my own knowiedge and belief.
Signature D. MENDOZA
Signature
Name in Print | Name in Print MARJQRIE D. SANTOS
Mother Midwife I
Relationshipto ihe
Address
Chid
ae As Above Tite or Position
January 23, 2017
Date
January 23, 2017
Date
24/RECEVED BY 25. REGISTEREDBY THE GVILGISTRAR
Signature Signature
Name in Print ALK T. BoMGAVAL Name in Print
ARLENE BMACASINAD
Titte or Position
ASS, RESTATIONF
Title or Position
FEB 16 2017
Date
REMARKSIANNOTATIONS (For LCRO/0CRG Use Only)
Date
FEB 162012
TO BEFILLED-UP AT THE OFFICE OF THE CIVILREGISTRAR
8 11
13 15 16 17
06773-E1-144SRT-00507-Bl003 BReN
BEST POSSIBLE IMAGE 07601-B17BLO6-6 LISA GRACE S. BERSALES, Ph.D.
National Statistician and Civil Registrar General
Documentary Philippine Statistics Authority
140T31440050707182018003 Stamp Tax Paid
