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.)

BENGUET
Province _________________________________________ Registry No.
City/Municipality ___________________________________
TUBA
09750
1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:
Population reference No.
ASHLY REA DIZON VELASCO
2. SEX 3. DATE OF BIRTH (day) (month) (year) 035838
______ 1 Male _______ 2 Female
11/01/1990
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
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER 41
L
D 5a. TYPE OF BIRTH b. IF MULTIPLE BIRTH, CHILD WAS 0 7 7 1 8 5 1
_____ 1 Single ______ 2 Twin _____ 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) T
FIRST
_____________ (first, second, third, etc.) 1587.57
________________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME 3 3 0 2 1 1 8
MA. JESSEBEL DELA CRUZ DIZON
7. CITIZENSHIP 8. RELIGION
56
M FILIPINO CATHOLIC
O 3 4 1 1 7
T 9a. Total number of b. No. of Children still c. No. of children
children born living including born alive but
H 1
alive: _________ 1
this birth: _________ 0
are now dead: _________
E 61
R 10. OCCUPATION 11. Age at the time 5
of this birth:
24
_______years
HOUSEWIFE
62 64
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province)
5 1 0 0 1 3
CAMP 6 TUBA BENGUET
13. NAME (First) (Middle) (Last)
68 69
F ALEX RAMOS VELASCO 1 1
A 14. CITIZENSHIP 15. RELIGION
T
H FILIPINO CATHOLIC 70 72 74
E
R 16. OCCUPATION 17. 9 6
3 8
Age at the time 7 8
of this birth:
FARMER 25
_______years
76 79
18. DATE AND PLACE OF MARRIAGE OF PARENTS (If not married, accomplish Affidavit of
Acknowledgement/Admission of Paternity at the back.)
5 5 1 5 2
_______________________________________________________________________________________________
19a. ATTENDANT
_____1 Physician ______ 2 Nurse ______ 3 Midwife 81
_____4 Hilot (traditional Midwife) ______ 5 Others (Specify)
_______________________________________________________________________________________________
5 7 8 0 0
19b. CERTIFICATION OF BIRTH
01/11/1990
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. 3:45AM
86 87
Signature ______________________________ CAMP 6 TUBA BENGUET
Address ______________________________
3 1
DR. JHON PAUL S.
Name in Print ___________________________ _____________________________________
AGAPE
OB GYN
Title or Position _________________________ 01/11/1990
Date _________________________________
_______________________________________________________________________________________________ 88 91

20. INFORMANT 2 0 1 5 1

Signature ______________________________ Address ______________________________

93
MA. JESSEBEL D. DIZON
Name in Print ___________________________ _____________________________________

MOTHER
Relationship to the child ___________________ Date ________________________________
5
_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
94
Signature ______________________________ Signature _____________________________ 3
JASMINE BAROSSO
Name in Print ___________________________ SHANE A. LAPIS
Name in Print __________________________

Certified Curse-Midwife
Title or Position _________________________ CLERK III
Title or Position ________________________
01/11/1990
Date __________________________________ 01/11/1990
Date _________________________________
_______________________________________________________________________________________________
 For this before 3 August 1988/on or after 3 August 1998

AFFIDAVIT OF ACKNOWLEDGEMENT/ADMISSION OF PATERNITY

MA. JESSEBEL DELA CRUZ DIZON

Well, ___________________________________________________ ALEX RAMOS VELASCO
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)

0095415
Community Tax No. _______________________ 0955844
Community Tax No. _____________________
Date Issued _______________________________
01/11/1990 01/11/1990
Date Issued ____________________________
BGHPMC
Place Issued ______________________________ BGHPMC
Place Issued ____________________________

11TH
SUBSCRIBED AND SWORN to before me this ___________ JANUARY
day of ____________________________, 1990
_________________
BAGUIO GENERAL HOSPITAL AND MEDICAL CENTER
at ___________________________________________________________________________________, Philippines.

_________________________________________ CLERK III

_______________________________________
(Signature of Administering Officer) (Title/Designation)

SHANE A. LAPIS
_______________________________________________ BENGUET, TUBA
___________________________________________
(Name in Print) (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) (Title/Designation)

_________________________________________________ ______________________________________________
(Name in Print) (Address)