-Municip;I Form No.

102
(Revised August 2016)
Republic of the Philippines
(To be accomplished in quadruplicate usin
. --
· g black ink)

OFFICE OF THE CIVIL REGISTRAR GENERAL

CERTIFICATE OF LIVE BIRTH

Registry No.
Province ________:S:.:...A::.:RA
:...:.:..c
N:.::G~A:!'.N~I_________ ______ _
~City/Municipality GLAN 202t-1a'36
1. NAME (First) (Middle) (Last)

_____ YlEKIA
_ _ HY __L_VA
_N_l~A:_,__ _ _ __ _,CAL
= l=
G=A";-'-
N - - - ----,-- -----.)~ABb-AS- - - -- - - - - ·
C 2. SEX (Male/ Female) 3. DATE OF (Day) (Month) (Year)
H FEMALE BIRTH l..f
. .......
I
4. PLACE OF
BIRTH
(Name of Hospital/Clinic/Institution/
House No. , St., Barangay)
(City/Municipality)
_

(Province) ---·
L
Q
GLAN MEDICARE COMMUNITY HOSPITAL pnRI Ann1J
5a. TYPE OF BIRTH 5b. IF MULTIPLE BIRTH, CHILD WAS
-· .
Sc.BIRTH ORDER (Orderoflhisbirtn to 1 u.~~•=HT AT BIRTH
(Single.Twin.Triplet. etc.) (First, Second. Third , etc.) previous live births including fetal death)
(First, Second. Third, etc. )
SINGLE __N.A. grams
SEtGND1---- -
7. MAIDEN (First) (Middle) (Last)
NAME
M MARY ANN

~H
DIV.AC, - ·-

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c_ =1
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_N:S
: H:IP
: : : : : ::~: : : :: : : :F..:: l,,,,L~
I...._
P:IN: 0:: : : :: : : : : : : :I:9· :R
: E:L~l
=:
G:10:N:/R:E:L:
IG:IO
: ~:s:_s:E:C:T.:.:-::: :::-_::::::: :: : : : :: ::
10a. Total number of 10b. No. of children still 10c. No. of children born 11 . 0CCUPATION ~• ,...,~,.._ 12. AGEatthetimeofthis
E children born alive living including this birth alive but are now dead birth (completed years)
2
R l--=---=====-_._J, - , - - - 2__ _ _Q ___ __ H
_O_USEKEEPING ')Q
13. RESIDENCE (House No., St., Barangay) (City/Municipality) (Province) (Country)
E. ALEGADO ST., POBLAOON
GLAN SARANGANI DUllll>l>I .. IC<"
14. NAME (First) (Middle) (Last)
F
ROEL
A 1 16. RELIGION/RELIG-;-;
___'l_lLLEGAS e. a• A
15. CITIZENSHIP IOccU,.;:S:-oS:-=E
c:c
C;;:-
T- 17. oc'c
~cc
u=pA
=:r=1o
~N- - - - -- a....i_113 _'""AGE at the time of this
T birth (completed years)
H RUPINO ____RO
_ MA
_ N_CA
_ T_
H_Oll_
C_ _~ - - ~M
~\ECl:IANI"',._
_·.,_c:_ _ _ _.___ .,.s-,,1--- - - ---t
E 19. RESIDENCE (Ho-u-se- No., St., Barangay) (City/Municipality) {Province) (CountfY)
R
1--~----
E._A
_L_EG
_ AD
_ O_S
_T_.,_P_OB
_ LA_C
_I_
O_N _ _ _ _G_LAN _ __ _:S
,e,A
C,,R
==>!
AN -'Cl(';
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N..._I_ _ __ ..,_.,
DU>ll.ll.ll<l'll>l'U'ff~"''"'-"'""> --- - - 1

~ Aa.RDRATIAE GE OF PARE_N_T_S_ ~ ot mar_rie_d, accompl~sh Affidavit of Ac_kn_owledgem':"~d:'.'ission o

_f_P_ate_rnity a_t_th_e_b_
ac_k_
.) _ _ _ _ __ _ _ _--t
1
"" 0 (Month) (Day) (Year) 20b. PLACE (City / Municipality) (Province) (Country)
NOVEMBER 18 2016 GIAN
--~S,~A=RA __=N
~ N,~G~.A _.,l_ _ _~P-l:llllee.1 ~•ce...__ _-1 1. .
21 a. ATTENDANT

_ 1 Physician _ _ 2 Nurse X 3 Midwife _ 4 Hilot (Traditional Birth Attendant) 5 Others (Specify)

_:....-..::==--_ _ ___:____:___::.:...=====-- 1
21b. CERTIFICATION OF ATTENDANT AT BIRTH (Physician, Nurse, Midwife. Traditional BirthAttendant'Hilot. etc.)
I hereby certify that I attended the birth of the child who was born alive at -tt,:SJ ~ am/pm on the date of birth specified above.

Signature ~ - - - - ----
CATALINA A. CASTANARES RM
Address GIAN-MEDICARcCOM:M.U
l"UT'rAOSPITAL
Name in Print_ __ _________ ~ - - - - - - -Gl:AN, SA-AANO-b.'Nr-PROVIN..,.CE-c--- - - - - - -
Title or Position NURSING ATTENDANT/ t,yQWlf_f.__ Date ----1..,;. 11 •• ,_
22. CERTIFICATION OF INFORMANT 23. PREPARED BY
I hereby certify that all information supplied are true and
correct to my own knowledge and belief.

Signature _ _ _ $]~·------- - ___ _ Signature ----~{oJ

'---------- -----
Name in Print _ _ROE
__L_V __AS
_I_LJ.EG ~~SAB
~ =LAS
~ - - ______
Name in Print.ADEI.E--E---Dne,-,..., I
~1-f'JffllllliOn-- -- - - - - - -
FA_T
Relationship to the Child ___ _H_E
_R~ - -- - -- ----
Title or PositiOJAE!>IEAl--~O:lfF'FFff'IC:EE'RR-..-fC;":10~.S.t--- - - - - - - -

a
Address E. ALEGADO ST., POBLACION GIAN, SARANGA.NI--
Date -----1-5--Jl:U,.,u:,E:.2~0h2t-1lt - - - - - - - - - - -
Date 15 JUNE 2021
24. RECEIVEDBY ~ 25. REGISTERED AT THE OFFICE OF THE CIVIL REGISTRAR

Signature _ _ _ _ - - -------- Signature

Name in Print SOywNu\RDAS
ADMIN. AIDE 1 · · .
NameinPri~GEll • ~~ t--- - - - -

Title or Position -..-..c---:-:-:-:-:--::--::-::--:--- - - - - - - - Title or PositReG...omcER=l,"

.., - - ~ -
-t---J~
-- -------
D~
2 2 JUN 2021 - Date ' ? II IM ?n'JI
REMARKS/ANNOTATIONS (For LCRO/OCRG Use Only)

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

B 9 11 13 15 16 17 19