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(Copy for OCRGJ
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• ~~:. No. 102 (To b. accomplished In quedruplicate) REMARKS/ANNOTATION
~.~~~~~ ~~(;"r~,J~\ary 1993)
•
0 Republic of Ihe Philippines
Ig~~~ .;;i.....,,·::::) 'I ",,~.

OFFICE OF THE CIVil REGISTRAR GENERAl

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A~'~'III\I,~I A.
CERTIFICATE OF LIVE BIRTH
(Fill out completoly. accut11le'y and legfbly. Use Ink oc 'YpewritM.
-:" '" d., -', Place X befOf8 the apprJlpriate answer In Item. 2. Sa, 5b and 19a.)

rP~e jN Ur-- - It\. - Y/I" , IR~If)Slry!_o. ( I ('!, I' ""-

City/Municipality vUOG050 IJvy ti.-C '/ 'f' I r
1. NAM E uIFl<lt) (Middle) _(Last) for OCRG USE ONLY:
~rk M~lT1n "uJ~ Populatton R.f ••• n••• No.

2. SEX
~ 1 Mal. __ 2 Fem~o
3. DATE OF BIRTH
(~)F.~(y~tlb3l--!=1TO=======1-1
liE fillED UP AT THE
OFFICE OF THE CML
C 4. PLACE OF (NarMof Ho,pItaJ/Olnic/lnstitutlon/ (Cily/Munlcipality) (Province) REGISTR.f,R
H
I
-~FV{\ot 1t~~N§:.~8~e:r~~ l!quaaboq, C.loocan City 41

l
D
5a. TYPE OF BIRTH
~ 1 Slngls __ 2 Twin
b.
__
IF MULnPLE BIRTH. CHILD WAS
1 flrt;I __ 2 Second
ITIIIIIJ·
3 Triple!. etc.

c. BIRTH ORDER (live births and fetal death.

1st Including this delivery)
I 3 OthlllS. Specify

d. WEIGHT AT BIRTH
217,; o
48

(flrlt ••• eond, third. atc.) grams

6. MAIDEN (Arat) (Middle) (Last) 41 50

NAME Rbeal,-n Tr,ston Nuja:· D CIIIIIJ

7. CITIZENSHIP 1 8. REUGION "athoUC
M 51
0 9a. Total number of b. No. ofchUdl1ln still C. No. of chlld'''n ~
T children bOrn living including 01 born allv. but 00
LL.L...L.-L:J
0'1
H alive: thla blrth: &1. now dead:

E 10. OCCUPATION 11. Age at tile timo S1

R olthls birth: 'i8
year. D
12. RESIDENCE (House flo .• Stre.t. Barangay) (City/Municipality) (Province)
62 &4
~••• u aMY.
F
13. NAME (Middle) (Last) LDITIIJ
51 8V
-- A
I'
.. :::::
T
H
R CITIZENSHIP

16. OCCUPATION
--~ S. REUGION

17. Age at the urne

DO 1-

E
olthla birth:
R ___ year' 70 72 74

lB. DATE AND PLACE OF MARRIAGE Of PARENTS (If not married. accomplish Affidavit Df
ACknowled~a'I/AdmilSion 01 Pat.rnlty atth, back.)
eo eo [IJ
7& 79
19a. ATTENDANT

__
1 Physician
~ Hilot (Traditional Midwife)
__
__
2 Nurse
5 Other. (Specify)
~3 Midwife ITIJ CD
19b. CERTIFICATION OF BIRTH 81
Ihereoy ool1ify that llIItInd.d
am/pm on the date slated above.
lhl birth of 1110
child who wu born alive at 7t45PM o'clock
CIIIJJ
lUk a 1 L , 5 :r.1R .:a..~:lC\IiIIhc",.
Signature
.•• /' ,•. I.. '" :. :.
. Addr&H __ -=.,.-- _
Fiu'5!:"'luaa OaloocaA City 88 87
Name In Print
Tille Of Position 0a1a 3"'1>03 0 0
20. INFORMANT
"
:
/' ( f'
. Addre", -'a/~D. _ 88 81
~m1h ~
SIgnature
Name in Print
RelationshlplOthechlld
Mother
_
--~13-0}
Oats --- _
ITTI OJ
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF 13
THE CIVIL REGISTRAR
\ D 1.620

I 05540-G8-003JRE-01114-81001 BReN ~~;5.~

BEST POSSIBLE IMAGE 07501 ..B03CSOQ-5 LISA GRACE S. BERSAlES, Ph.D.
National Statistician and Civil Registrar General
11111111111111111111111111111I111111111111I111111I11111111 Documentary
Philippine Statistics Authority
T003055400030111403032015001 Stamp Tax Paid
JJ500925385