aceomplished n glupit aln

(o te
Municipal Fom No. 102
Republc of the at in
(Revised August 2016) REGISTEAlGL NEKAL
OFFICE OF THE CIVIL
CERTIFICATE OF LIVE BIRTH
Regstry No
2022 637
Provnce SARANGANI

City Municipality KIAMBA

1 NAME UNCC)Y
KIAN
AMARVIN AY
DATL OE
SEXAM enLe) MAY
IRTH
MALI
4 PLACE F
N
BIRTR KIAMIA
MALIGANG S) IE MUL WL LRCHL D WA
5a IYPE OF BIRIH
grams
NOT APUCABLE NINTH
SINGLE
(Mtde
7 MAIDEN (First)
USMAN KHAN
NAME
MARIAL YN 9 RELIGIONRELIGIOUS SECT
M
8CITIZENSHIP M
0EIWL 12 ACGE at thee time of thes
FILIPINO
T 10b No of childen still
10c No of children born 11 O
brth ompiete
H 10a Total number of alive but are now dead
HOUSEKEEPER OWN HOMF
children born alive
living including this birth

7 Countre
R (House No St., Barangay) (City/Munpality) (Provinc0
13 RESIDENCE PHILIPPINE S
SARANGANI
MALIGANG
KIAMBA
(Middle)
14 NAME (First)
F UNGOY
TITING
SILAM 18 AGE at the ime f ihs
A 16 RELIGION/RELIGIOUS SECT 17 OCCUPATION
15 CITIZENSHIP birth

CORN FARMER 38
FILIPINO
(City Muncipality) (Provnce) Countr
19 RESIDENCE House No St Bargay)
SARANGANI PHILIPiNES
R MALIGANG
KIAMBA
Acknowledgement/AdmissIon of Paternity at the back
MARRIAGE OF PARENTS not maried accomplish [Link] of
20b PLACE (City / Munt p. lity 1Drov
20a DATE (Month Year)
SARANGANI PHILIPPINES
DECEMBER 19, 2004 KIAMBA

21a ATTENDANT
X 4 Hilot (Traditional Birth Attendant) 5 Others (Specify)
1 Physician 2 Nurse 3 Midwife
Birth Attendant Hilot ete
21b CERTIFICATION OF ATTENDANTAT BIRTH (Physic1an Nurse Mdwfe, Traditional above
I hereby cert1fy that Iattended the birth of the child who
was born alive at 05 30 AM am/pm on the date of birth spec1tied

Address
Signature NOT AVAILABLE
Name in Print LOLITA BACUNA
Title or Pos1tion Date
HILOT
22 CERTIFICATION OF INFORMANT
23 PREPARED BY
Ihereby certify that all informat1on supplied are true and
correct to my own knowledge and belief

Signature Signature

Name in Print FEUCITASA TAKA Name n Print tYRAL ANCHETA

Relationship to the Child
AÇQUAINIANCE Title or Position ADMINISTRATIVE AIDE
Address MALIGANG, KIAMBA, SARNGANI Date MAY 25 2022
Date MAY 25, 2022
24 RECEIVED BY
25 REGISTERED AL THE *ErHE CIV RrGISTRAR
Signature
Signature
Name in Print JEANE /IE EHURANGO Name in Pnt JEANETG EHURRNGO
Title or Position ADNN ASSISTANT | Tite or Poston AS MUN CIVIL REGISTRAR
Date MAY 25, 2022 Date MAY 25, 2022
REMARKS/ANNOTATIONS (For LCRO/OCRG Use Only) THE
A LINICPa.

REGISTEREDPURSUANT TO RA 8371
PAL CVI

TO BE FILLED-UP AT THE OFFICE OF THE CIVIL REGISTRAR

3A. 9ARANGAS
11 13 15 16 17
8

0 1 3 1 02 1 6 0 8 0 8 0 0 3 0 1 3 1 6 1 1 6 0 8 0 8 0 0 3