Municipal Form No.
102
(Revised January 1993)
(To be accomplished in quadruplicate)
REMARKS/ANNOTATION
Republic of the Philippines
OFFICE OF THE CIVIL REGISTRAR GENERAL
CERTIFICATE OF LIVE BIRTH
(Fill out completely, accurately and legibly. Use ink or typewriter.
Place X before the appropriate ANSWER IN ITEMS 2, 5A, 5B AND 19A.)
Nueva Ecija
Province _________________________________________
Cabanatuan
City/Municipality ___________________________________
1. NAME
(First)
Registry No.
78654
(Middle)
Monica
Santos
2. SEX
3. DATE OF BIRTH
4. PLACE OF
BIRTH
(day)
(City/Municipality)
5a. TYPE OF BIRTH
b.
_____ 1 Single
______ 2 Twin
______ 3 Triplet. Etc.
c. BIRTH ORDER (live births and fetal deaths
M
O
T
H
E
R
CITIZENSHIP
9a.
Total number of
children born
alive: _________
2
(Middle)
Teehankee
Roman Catholic
c. No. of children
No. of Children still
living including
this birth: _________
2
born alive but
are now dead: _________
11.
None
50
Santos
8. RELIGION
(House No., Street, Barangay)
48
49
(Last)
10. OCCUPATION
12. RESIDENCE
________________
3000grams
Filipino
b.
______ 2 Second
Others, Specify _____________
d. WEIGHT AT BIRTH
including this delivery)
first
_____________
(first, second, third, etc.)
Monina
41
IF MULTIPLE BIRTH, CHILD WAS
_____ 1 First
______ 3
(First)
TO BE FILLED UP AT THE
OFFICE OF THE CIVIL
REGISTRAR
(Province)
Good Samaritan General Hospital, Burgos Avenue, Cabanatuan City
7.
897996
(month) (year)
January 23, 2005
(Name of Hospital/Clinic/Institution/
House No., Street, Barangay)
6. MAIDEN
NAME
Population reference No.
Cruz
______ 1 Male _______ 2 Female
C
H
I
L
D
FOR OCRG USE ONLY:
(Last)
56
4 4 4
61
Age at the time
of this birth:
25
_______years
(City/Municipality)
(Province)
62
64
68
69
70
72
Lot 1 Blk 2 Univille Subdivision, Bangad, Cabanatuan City, Nueva Ecija
13. NAME
F
A
T
H
E
R
14. CITIZENSHIP
(First)
(Middle)
Arsenio
Tupaz
(Last)
Cruz
15. RELIGION
Roman Catholic
Filipino
16.
OCCUPATION
17.
Age at the time
of this birth:
_______years
30
18. DATE AND PLACE OF MARRIAGE OF PARENTS (If not married, accomplish Affidavit of
76
Jeepney driver
74
3 4
5 6 8
19a. ATTENDANT
_____1 Physician
______ 2 Nurse
______ 3 Midwife
_____4 Hilot (traditional Midwife)
______ 5 Others (Specify)
_______________________________________________________________________________________________
81
4 5 4
19b. CERTIFICATION OF BIRTH
2:00
I hereby certify that I attended the birth of the child who was born alive at ______________oclock
am/pm on the date stated above.
Signature ______________________________
ALYSSA SEVILLA
Name in Print ___________________________
Address ______________________________
U908 Manila Astral Tower
86
OB-GYNE
Title or Position _________________________
Date _________________________________
_______________________________________________________________________________________________
87
_____________________________________
P. Faura St., Ermita, Manila
January 23, 2005
88
20. INFORMANT
Signature ______________________________
Liza Batungbakal
Name in Print ___________________________
Address ______________________________
U908 Manila Astral Tower
P. Faura St., Ermita, Manila
_____________________________________
93
Relationship to the child ___________________
Date ________________________________
Grandmother
January 23, 2005
_______________________________________________________________________________________________
21. PREPARED BY
22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
Signature ______________________________
Signature _____________________________
Maika Hontiveros
Name in Print ___________________________
Paula Tanoco
Name in Print __________________________
Secretary
Head nurse
Title or Position _________________________
Title or Position ________________________
January 23, 2005
Date __________________________________
Date _________________________________
January 30, 2005
_______________________________________________________________________________________________
94
79
Acknowledgement/Admission of Paternity at the back.)
_______________________________________________________________________________________________
91
For this before 3 August 1988/on or after 3 August 1998
AFFIDAVIT OF ACKNOWLEDGEMENT/ADMISSION OF PATERNITY
Well, ___________________________________________________ and ____________________________________
parents/parent of the child mentioned in this Certificate of live Birth, do hereby solemnly swear that the information contained herein are true
and correct to the best of our/my knowledge and belief.
_________________________________
(Signature of Father)
_______________________________
(Signature of Mother)
Community Tax No. _______________________
Date Issued _______________________________
Place Issued ______________________________
Community Tax No. _____________________
Date Issued ____________________________
Place Issued ____________________________
SUBSCRIBED AND SWORN to before me this ___________ day of ____________________________, _________________
at ___________________________________________________________________________________, Philippines.
_________________________________________
_______________________________________
(Signature of Administering Officer)
_______________________________________________
(Name in Print)
(Title/Designation)
___________________________________________
(Address)
Not applicable for births before 27 February 1931
AFFIDAVIT FOR DELAYED REGISTRATION OF BIRTH
(Either the person himself if 18 years old or over, or father/mother/guardian may accomplish this affidavit.)
I, ____________________________________________________________________, of legal age, single/married
and with residence and postal address at _____________________________________________________________________,
after having been duly sworn to in accordance with law, do hereby depose and say:
1. That I am the applicant for the delayed registration of my birth/of the birth of
_______________________________________________________.
2. That I/he/she was born on ____________________ at _____________________________________________.
3. That I/he/she was attended at birth by _______________________________________________who resides at
_____________________________________________________________________________.
4. That I/he/she is citizen of _________________________________________________________.
5. That my/his/her parents were
married on ____________________ at _______________________
_______________________________________________.
not married but was acknowledge by my/his/her father whose
name is ________________________________________________.
6. That the reason for the delay in registering my/his/her birth was due to ________________________________
________________________________________________________________.
7. That a copy of my/his/her birth certificate is needed for the purpose of ________________________________
________________________________________________________________.
8.
(For the applicant only) That I am married to ________________________________________________.
(For the father/mother/guardian) That I am the ________________________________ of the said person.
_________________________________________
(Signature of Affiant)
Community Tax No. ________________________
Date Issued _______________________________
Place Issued ______________________________
SUBSCRIBED AND SWORN to before me this _________ day of _______________________, ______________
at ____________________________________________________________________ _______________, Philippines.
________________________________________
(Signature of Administering Officer)
_________________________________________________
(Name in Print)
_____________________________________
(Title/Designation)
______________________________________________
(Address)
