birthcertificate-FATIMA

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Municipal Form No.

102 (To be accomplished in quadruplicate)


(Revised January 1993) 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.)

Province _________________________________________
TAWI-TAWI Registry No.
City/Municipality ___________________________________
BONGAO

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


Population reference No.
FATIMA ALSREERHAFIA KAYTING HASSAN
2. SEX 3. DATE OF BIRTH (day) (month) (year)
X 2 Female
______ 1 Male _______
12 JULY 2017
TO BE FILLED UP AT THE
C 4. PLACE OF (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) OFFICE OF THE CIVIL
H BIRTH House No., Street, Barangay) REGISTRAR
I TUBIG MAMPALLAM, BONGAO, TAWI-TAWI 41
L
D 5a. TYPE OF BIRTH b. IF MULTIPLE BIRTH, CHILD WAS
_____ 1 Single ______
X 2 Twin _____
X 1 First ______ 2 Second
______ 3 Triplet. Etc. ______ 3 Others, Specify _____________
48

c. BIRTH ORDER (live births and fetal deaths d. WEIGHT AT BIRTH


including this delivery)
3RD (first, second, third, etc.)
_____________
3,500
________________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME
VANESSA MACAM KAYTING
7. CITIZENSHIP 8. RELIGION
FILIPINO ISLAM 56
M
O
T 9a. Total number of b. No. of Children still c. No. of children
children born living including born alive but
H 4
alive: _________ 4
this birth: _________ 0
are now dead: _________
E 61
R 10. OCCUPATION 11. Age at the time
of this birth:
PRIVATE EMPLOYEE 35
_______years

62 64
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province)
TUBIG MAMPALLAM, BONGAO, TAWI-TAWI
13. NAME (First) (Middle) (Last)
68 69
F JAAPAR HAMIDOL HASSAN
A 14. CITIZENSHIP 15. RELIGION
T
H FILIPINO ISLAM
70 72 74
E
R 16. OCCUPATION 17. Age at the time
of this birth:
PRIVATE EMPLOYEE 36
_______years
76 79
18. DATE AND PLACE OF MARRIAGE OF PARENTS (If not married, accomplish Affidavit of
Acknowledgement/Admission of Paternity at the back.)
AUGUST 12, 2004 BONGAO, TAWI-TAWI
_______________________________________________________________________________________________
19a. ATTENDANT
_____1 Physician ______ 2 Nurse X 3 Midwife
______ 81
_____4 Hilot (traditional Midwife) ______ 5 Others (Specify)
_______________________________________________________________________________________________
19b. CERTIFICATION OF BIRTH
4:07am
I hereby certify that I attended the birth of the child who was born alive at ______________o’clock
am/pm on the date stated above.
86 87
Signature ______________________________
BONGAO, TAWI-TAWI
Address ______________________________
SALMA M. KAYTING
Name in Print ___________________________ _____________________________________

RHU MIDWIFE III


Title or Position _________________________ JULY 14, 2022
Date _________________________________
_______________________________________________________________________________________________ 88 91

20. INFORMANT

Signature ______________________________ BONGAO, TAWI-TAWI


Address ______________________________
93
JAAPAR H. HASSAN
Name in Print ___________________________ _____________________________________

FATHER
Relationship to the child ___________________ JULY 14, 2022
Date ________________________________
_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
94
Signature ______________________________ Signature _____________________________

Name in Print ___________________________ Name in Print __________________________

Title or Position _________________________ Title or Position ________________________


Date __________________________________ Date _________________________________
_______________________________________________________________________________________________

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