Municipal Form No.
102 (To be accomplished in quadruplicate using black ink)
(Revised January 2007) Republic of the Philippines
OFFICE OF THE CIVIL REGISTRAR GENERAL
CERTIFICATE O F LIVE BIRTH
Province Registry No.
LEYTE
2015-02-14
City/Municipality PALO, LEYTE
1. NAME (First) (Middle) (Last)
c
MARIAH FABREGAS VERGARA
2. SEX (Male / Female) 3. DATEOF (Day) (Month) (Year)
FEMALE BIRTH 14 FEBRUARY 2018
4. PLACE OF (Name of Hospital/Clinic/lnstitution/ (City/Municipality) (Province) BIRTH House No.. St., Barangay)
EASTERN VISAYAS MEDICAL CENTER, TACLOBAN CITY, PHILIPPINES
5c. BIRTH ORDER(Order ofthis birth to previous live 6.
5a. TYPE OF BIRTH 5b. IF MULTIPLE BIRTH, CHILD births including fetal death)
WEIGHTAT BIRTH
(Single,[Link], etc,) WAS (First. Second. Third. etc.)
(First, Second, Third, etc.)
SINGLE 2.24 grams
7. MAIDEN (First) (Middle) (Last)
o NAME
MA. NICOLETTE RICALDE FABREGAS
8. CITIZENSHIP 9. RELIGION/RELIGIOUS SECT
FILIPINO ROMAN CATHOLIC
10a. Total number of 10b. No. of children still IOC. NO. Of children bom 11. OCCUPATION 12. AGE at the time of this
children born living including this binh alive but are now birth (completed years)
alive dead
PRIVATE EMPLOYEE 27
13. RESIDENCE (House NO., St., Barangay) (City/Municipality) (Province) (Country)
ZONE 2, BRGY. LUNTAD, PALO, LEYTE, PHILIPPINES
14. NAME (First) (Middle) (Last)
JOHN II GAVIOLA VERGARA
18. AGE at the time of tlis biffi
15. CITIZENSHIP 16. RELIGION/RELIGIOUS SECT 17. OCCUPATION
(completed years)
FILIPINO ROMAN CATHOLIC PRIVATE EMPLOYEE 28
19. RESIDENCE (House No., st., Barangay) (City/Municipality) (Province) (Country)
ZONE 3, CAVITE EAST, PALO, LEYTE, PHILIPPINES
MARRIAGE OF PARENTS (If not married, accomplish Affidavit of Acknowledgement/Admission of Paternity at the back.)
20a. DATE (Month) (Day) (Year) 20b. PLACE (City / Municipality) (Province) (Country)
FEBRUARY 12 2015 PALO LEYTE PHILIPPINES
21a. ATTENDANT
_X_ 1 Physician 2 Nurse 3 Midwife 4 Hilot (Traditional Birth Attendant) 5 Others (Specify)
Address
1b. CERTIFICATION OF ATTENDANT AT BIRTH(Physician, Nurse, Midwife, Traditional
Birth etc.)
I hereby certify that I attended the birth of the child who was born aliveat 1:25 PM am/pm on the date of birth specified above.
Signature ______________________ Address EASTERN VISAYAS MEDICAL CENTER
Name in Print MALINE GRAY COSIDO
Title or Position OB-GYNE Date February 14, 2015
23. PREPARED BY
22. CERTIFICATION OF INFORMANT Signature
I hereby certify that all information supplied are true and
correct to my own knowledge and belief.
Name in Print MILDRFD B FABFLI_A
Title or Position
Signature
HOSPITAL CLERK
Name in Print RALPH S. LOPEZ Date DECEMBER
Relationship to the Child FATHER 25
Date DECEMBER 25 2012 2012
24. RECEIVED BY 25. REGISTERED BY THE CIVIL REGISTRAR
Signature Signature
Name in Print SOFIA M. REGATON
Name in Print JENETTE
L. ROBLES
Title or Position Title or Position CHIEF REGISTRAR
CLERK I Date JANUARY 2 2013
Date DECEMBEROO 2012
REMARKS/ANNOTATIONS (For LCRO/OCRG Use only)
TO BE FILLED-UP AT THE OFFICE OF THE CIVIL REGISTRAR
AFFIDAVIT OF ACKNOWLEDGMENT/ADMISSION OF PATERNITY
(For births before 3 August 1988) (For births on or after 3 August 1988)
l/We, and
of legal age, am/are the natural mother and/or father of who was
born
on
I am / We are executing this affidavit to attest to the truthfulness of the foregoing statements and for purposes of
acknowledging my/our child.
(Signature Over Printed Name of Father) (Signature Over Printed Name Of Mother)
SUBSCRIBED AND SWORN to before me this day of by and ,
who exhibited to me (his/her)
at
Signature of the ministering Officer Position / Title / Designation
Name in Print Address
AFFIDAVIT FOR DELAYED REGISTRATION OF BIRTH
(To be accomplished by the hospital/clinic administrator. father, mother, or guardian or the person himself if 18 years old or over,)
age, single/married/divorced/widow/widower,with
residence
after having been duly sworn in accordance with law, do hereby depose and say:
I. That I am the applicant for the delayed registration of:
2. That
l/he/she was attended at birth by who resides at
3. That I am/he/she is a citizen
of
4. That
my/his/her parents were
father whose
5. That the reason for the delay in registering my/his/herbirth was
6. (For the applicant only) That I am married to
(If the applicant is other than the document owner) That I am the of the said person.
7. That I am executing this affidavit to attest to the truthfulness of the foregoing statements for all legal intents and
purposes.
my signature belowthis day of
Philippines.
(Signature Over Printed Name of Affiant)
to before me this day of
Cert.
at
Signature Of the Administering
N me in Print
