___________________________________________________________

_________________________________________________________________________________________
Municipal Form No.102

________________________________________________________
(To be accomplished in quadruplicate)

_________________________________________________________________________________________
(Revised January 1993)
Republic of the Philippines

CERTIFICATE OF LIVE BIRTH

(fill out completely, accurately and legibly. Use ink or typewriter
___________________________________________
Place X below the appropriateanswer in item 2, 5a, 5b, and 19a.)

______________________ Registry No.

____
Province
City/Municipality __________________
Manila 88-18585
___________________________________________________________
____________________________________________

1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:

Population Reference No.
_________________________________________
ANDY JAY BAS GEOLLEGUE
5515-A-15-1100-11

___
2. SEX 3. DATE OF BIRTH (day) (month) (year)
_________________________________________
X ______ 1 Male 13 March 1988
______ 2 Female TO BE FILLED UP AT THE

C
4. PLACE OF (Name of Hospital/Clinic/Institution
House No. Street Barangay)
(City Municipality) ( Province)
_______________ OFFICE OF THE CIVIL
REGISTRAR
H BIRTH
_________________________________________
Dr. Jose Fabella Memorial Hospital 41

1 5 0 0 9 2 1
I ____
L 5a. TYPE OF BIRTH X b. IF MULTIPLE BIRTH, CHILD WAS
______ 1 First _______ 2 Second
_________________________________________
D ______ 1 Single _______ 2 Twin
______ 3 Triplet, etc. _______ 3 Others, Specify _______________________
40
____
c. BIRTH ORDER d. WEIGHT AT BIRTH (live births and fetal deaths
______
FIRST ______
3583
___________________________________________ including this delivery)
( first,second,third, etc.) grams 1
6. MAIDEN (First) (Middle) (Last) 49 50
_________________________________________
NAME Jennifer Geollegue 1 6 1 5 3
___

7. CITIZENSHIP 8. RELIGION
_________________________________________
Filipino Roman Catholic 56

5 5 1 5 2
____

___ ____

9a. Total number of b. No. of children still c. No. of children

M
O
alive ____
children born
____ ____
living including
_________________________________________
1 1 this birth 0 born alive but
now are dead
61
T 10. OCCUPATION
1
11.
H ___
_________________________________________
Housewife 18
Age at the time
of this birth years
E
(House No. Street, Barangay,) (City Municipality) ( Province) 62 64
R 12. RESIDENCE
___________________________________________
2796 Bo Sto. Niño, Pasay City 0 3 3 8 2 1
13. NAME (First) (Middle) (Last)
F _________________________________________
N/A
A 68 69
___

14. CITIZENSHIP N/A 15. RELIGION

1 1
N/A
H _________________________________________
T

___
___

E 16. OCCUPATION 17. Age at the time

R
N/A
___________________________________________ N/A of this birth years
70 72 74

18. DATE AND PLACE OF MARRIAGE OF PARENTS (If not married, accomplish affidavit of
0 2 0 2 0 2
Acknowledgement/Admission of Paternity at the back )

N/A N/A
_________________________________________ 76 79

19a. ATTENDANT
7 2 0 2 5
__________ 1 Physician __________ 2 Nurse ____________ 3 Midwife
_________________________________________
__________ 4 Hilot (Traditional Midwife) __________ 5 Others (Specify ________________________________
81

5 5 1 5 2
19b. CERTIFICATION OF BIRTH
11:45 PM
I hereby certify that I attended the birth of the child who was born alive at ____________________ o'clock
am/pm on the date specified above.

Signature _________________________________________
Dr. Jose Fabella
Address ___________________________________________
86 87
Memorial Hospital
DR. NEBAB
Name in Print _____________________________________ _____________________________________________________
1 1 N
_________________________________________
Physician
Title or Position___________________________________ Mar. 13, 1988
Date _______________________________________________

20. INFORMANT
2796 Bo Sto. Niño, 88 91

2 5 4 3 3
Signature _________________________________________ Address ____________________________________________
Jennifer Geollegue ______________________________________________________
Name in Print _____________________________________ Pasay City
_________________________________________
MOTHER
Relation to the child ______________________________ Mar. 13, 1988
Date ________________________________________________
92

1 051492
_________

21. PREPARED BY 22. RECEIVED AT THE OFFICE OF

55887
THE CIVIL REGISTRAR
SYLVIA M. AMADAN
Signature _________________________________________

02295
Signature _________________________________________
MA. CHEIREE MAE DE JESUS
Name in Print _____________________________________ 93
ADMINISTRATIVE OFFICER 1 CITY CIVIL REGISTRAR 3
Title or Position ___________________________________
Name in Print _____________________________________

Title or Position ___________________________________

MAR. 14, 1988
___________________________________________________________
14-APR-1988
Date ______________________________________________ Date ______________________________________________

07940-7H-999R16-04902-BI001

CLAIRE DENNIS S. MAPA, Ph. D.

National Statistics and Civil Registrar General
T089079409990490209272021001 Philippine Statistics Authority