Republic Registrar: Remarks

Page 1 of 1, 1 Copy
(Copy for OCRG) REMARKS/ANNOTATION

STATIS
OPINS
PHILI
Par OCRO USE ONLY: Population Rolerenga Wa.
TO DE PE
al Forma Ho. 102
(To be accomplished in quadruplicata) sed January 1993)
Republic of the Philppines OFFICE OF THE CIVIL REGISTRAR
GENERAL
CERTIFICATE OF LIVE BIRTH FR out completon, Locurgaly and legibly. Use ink or typewriter. Piace
X before the appropriate answer in Moms 2, 5a, 66 and 1948.)
CAMARINES NCSTE Province -

Registry No. City/Municipality DAET
2002-3037 1. NAME
(First)
Middie)
(Last) BEQINE DANO
PENCIL
DACATIMBANG 2. SEX
3. DATE OF BIRTH (day) (monm) jaar) L
Adale _ * 3 Femele
24 AUGUST 2002 4. PLACE OF Name of Hospital/Clinic/Institution/
(City/Municipality) (Province) H BIRTH House No., Street, Barangay) + CAMARINES
NORIE PROVINCIAL SOFITAL DAET CAMARINSS NOWE
så. TYPE OF BIRTH

b. IF MULTIPLE BIRTH, CHILD WAS Single
2 Twin
Frst
2 Second - 3 Triplet, etc.
- 3 Others, Specity ive births and fatal deaths |d. WEIGHT AT BIRTH
including this delivery) Second first, second, third, etc.)
2600 grama 6 MAIDEN (First)
(Middla) - NAME
GINA
ABOSTAN
PEKCII 1.7. CITIZENSHIP
8. RELIGION FILIPINO
BOMAN CATHOLIC Sa. Total number of
b. No. of children still
C No.of children children bom
Hiving including
born alive but alive:
this birth:
are now dead: 10. OCCUPATION

11. Age at the time
of this birth: Lousekeeper
| 12. RESIDENCE (House No., Street, Barangay)
(City/Municipality Province)
Moreno Dist, Daet, Camarines Norte F13. NAME
(First)
(Middle)
(Last) ACMEO JR JCVERO
DACATIMBANG 14. CITIZENSHIP
15. REUGION FILIFINO
RQIAN CAIHOLIC 16. OCCUPATION
17. Age at the time
aithis bith: Painter
32_years 18.
DATE AND PLACE OF MARRIAGE OF PARENTS (f not
married, accomplish Affidavit of
Acknowledgment/Admission of Paternity at the back.)
September 9, 1995-Daet, Camarines Norte 190. ATTENDANT
iPhysician
2 Nurse
3 Midwife - Hilot (Traditional Midwite)
5 Others (Specity) 15b. CERTIFICATION OF BIRTH
Theraby oshtity that I mitended the birth of the child who was bom alive at_
11:30_m o'clock amjpm on the date stated above
mos
.
30
years
.
<
I
w
Ö Ő 02950
to
Signature
-
Signature
Address_Cam. Norte Dorli Hord Marme in Pride VERNA P. IZANO
Daet, Camarines Norte Title of Position: Nurse_I
Date Sept. 3. 2002 20. INFORMANT
1. Ronne J. Doodhay Part
ress Moreno Diat. Daet Name in Print A
Bond ADHBO J. DACATDMEUNG JE.
B
Camarines Norte Relationship to the child father
Date Sept. 3. 2002 21. PREPARED BY
22. RECEIVED AT THE DFFICE OF
THE CIVIL REGISTRAR dom Signature
MARILYN S, SUS.NO
Signature - Name In Print
Name in Print LEUS LORD Title or Position Records Officer IT
Title or Position LUNCU RAISIRARI Date Sept3. 2002
_ 24_ HIDE_2002 TI
‫ بہن‬،‫ سن‬:
06767-16-134MEM-00546-BI001 BEST POSSIBLE IMAGE

BREN 01603-BO2RQ02-4
Grace s. Bersales
Lisa
LISA GRACE S. BERSALES, Ph.D. National Statistician
and Civil Registrar General
Philippine Statistics Authority
Documentary Stamp Tax Paid
T134067671340054607122018001
LM600091637
2158747
"NICIPAL FORM No. 102–(Revised De: 1, 1958)

STO BE ACCOMPIJSHED IN DUPLICATE) REPUBLIC OF THE
PHILIPPINES CERTIFICATE OF LIVE BIRTH
ale (FILL OUT COMPLETELY, ACCURATELY, LEGIBLY IN INK
OR TYPEWRITER)
Register Number: Prexrince. ....Canarias...

Jose................... (a) Civil Registrar-General No. ...
City of Municipality: ........
.
. ......
(6) Local Civil Registrar No. .... 4 02 Pace or BIRTR
2. USUAL RESIDENCE OF MOTHER (Where does motbee live?) :
PROVINCE Comises Norte__
a. PROVINCE Cervign lorto 6. CITY OR MUNICIPALITY
8. CITY OR MUNICIPALITY
26.$_ C. NAME OF HOSPITAL OR INSTITUTION 1: not in hospital, give streut i c.
NUMBER. AND STREET
address)
d's Place Of Birra INSIDE CITY LINITS?
YES
Yes
No a 8. NAN: (Type or print)
First
‫اعدة‬
CHILD
d. Is RESIDENCE INSIDE CITY . Is RESIDENCE ON A FARX?
LATTS? YES O NO
YES NO O Middle
ABUSTIL 56. IF TWIN Oz TRIPLET, WAS CEILD | 6. DATE OF BIRTA
isto 2ND D 3RD D Last
RELIGION
NATIONALITY 8. RICE
4. Se:
64. THIS BIRTB 1 SINGLE
First
TWIN
TRIPLst o l Middle
[ 7. NAME
FATHER,
9. Aga (At time of
Lhis birth)
7 10. BIRTHPLACE
112. USCAL OCCUPATION
[116. KIND OF BUSINESS OR IN
DUSTRY
Years
RESERVE FOR BINLING
stanazizar los
Last RELIGION,
( 12. MAIDEN NAME
First
Middle
- 13. NATIONALITY
| 13a. Race
MOTHER
16. PREVIOU3 DELIVERIES TO MOTIEK
(Do not include this birth)
4. AGS (At time of i 15. BIRTHPLACE
this birth)
Years 19. 176. INT ORMANI'S SIONATURE:
(S. NAMB IN PRINT:
Daes sanaa korse C. ADDRZSS 18. MOTEEB'S MAIZING ADDRESS:
(Number, Street, City or Mucicipality Province)
a. How many
children are DOV liviag?
6. How many otberic, Yow many fetal
children were deats (ietuses born alive but born cead any are now dead?
time after coa cepdon)?
6. NAMO IN PRINT: -I
TORE
19.
I H OOL CERTIFY that I amended the birth of thie chod wbo was
ATTENDINT AT BIRTU
born . DATE SIGNED BY ATTENDANT AT Binta: allye at a o'clock 24. on the

date above jadicated.
2. S10ATURE:..
2. TITLE OF ATTENDANT AT Nyu: & NAME IN PRIHS:
352TA
O M.D.
MIDW1F23 8. ADDRESS:
2
Maria
ONURSE
OTHERS (Sterily) 20 RECEIVED IN THE OFFICE C2 TRZ LOCAL. CIVIL
REGISTER BY: 21. a. GIVEN NAME ADOLD FROM SCILEMENTAL REPORT:
8. SIONATURE: - b. NAME IN PRINT:
3. DATE WHEN Givex NASIE WAS SUPPLIED: 6. TITLD OR Posities: - SAL-

SEVE D ESTRAR d. DATE: -
- estee 2:20. LENGTR OF PEONARUZ

226. gaf at BIRTH
28. LEGITI ----Lh3. -----0z!
No 24. DATE AND PLACE OF MARRIAGE OF PARENTS (for legitimate bizi.)
25. Tons CERTIFICATS 13 l
SION47 URA:
TAR! IN PRINT. ------- 201 (Mootb)

(Dute;
TITLE OR POSITION: Clay or Blvatcipolley ----Re p ortes -

G enel Dars: 18- 289
(SPACE FOR MEDICAL AND HEALTH IS FOR SPECIAL PURPOSES)
COMPLETED WCLK3.
da guglu
20_1972
2
TATAIS
i Gmia A. Pencil
may le, 1972 Claet, Cans route
A CERTIFIED TRUE COPY OFFICE OF THE CIVIL

REGISTRAR-GENERAL:
Amorias
NORMALE M. ORIAS Statistician Aide

BUWS
PILIPINAS
INTERNAS
REPUBLIKA
ASINDA ANASENASINTERNASRANANG
SLIKA NG PILIP
TASINIERNASRENTASINIERNASRINLASS
0084659864
REPUBLIC
PILIPINAS
SNIASISIRENANTAISIERSASEMIAS RENASISIEKSNASISIENAS
BUWIS
PILIPINAS
REPUBLIKA
RENT
SE INTERNAS
PAINIASINJERNASRESTASIN ERUASRENTASIE
E 0084659865
ERNASRENIASINTERNASREN
DATE VERIFI
REPUBLIC
VERIFIED BY:
gouro
AFFIX DOC. STAMP

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Page 1 of 1, 1 Copy

(Copy for OCRG) REMARKS/ANNOTATION

Par OCRO USE ONLY: Population Rolerenga Wa.

CAMARINES NCSTE Province -

så. TYPE OF BIRTH

are now dead: 10. OCCUPATION

06767-16-134MEM-00546-BI001 BEST POSSIBLE IMAGE

"NICIPAL FORM No. 102–(Revised De: 1, 1958)

Register Number: Prexrince. ....Canarias...

d's Place Of Birra INSIDE CITY LINITS?

born . DATE SIGNED BY ATTENDANT AT Binta: allye at a o'clock 24. on the

3. DATE WHEN Givex NASIE WAS SUPPLIED: 6. TITLD OR Posities: - SAL-

- estee 2:20. LENGTR OF PEONARUZ

TAR! IN PRINT. ------- 201 (Mootb)

TITLE OR POSITION: Clay or Blvatcipolley ----Re p ortes -

A CERTIFIED TRUE COPY OFFICE OF THE CIVIL

NORMALE M. ORIAS Statistician Aide

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