Page , 1 of 1, 1 Copy

Copy for OCRG

Municipal Form No. 102 To be accomplished In quadruplicate REMARK/ANNOTATION

Registed January 2010
Republic of the Philippines
OFFICE OF THE CIVIL REGISTRAR GENERAL
CERTIFICATE OF LIVE BIRTH
(Fill out completely, accuratelyand legitby, Use ink or typewriter
Please X before appropreses answer items 2, 5a, 5b, and 19a.)

Province METRO MANILA Registry No.

City/Municipality TAGUIG CITY 2010-022
1. NAME (First) (Middle) (Last) For OCRG USE ONLY.
Pupolation Reference No.
KRIZZ ANGELINE BARING AGAMATA
2. SEX 3. DATE OF BIRTH (Day) (Month) (Year)
X
____ 1 Male ______ 2 Famale 22 OCT 2010 TO BE FILLED-UP OF THE
OFFICE OF THE CIVIL
C 4. PLACE OF (Name of Hospital/Clinic/Institution (City/Municipality) (Province) REGISTRAR
H BIRTH
House No. St, Barangay)

I 41
40 PRK, 4V BALAGTAS ST. LOWER BICUTAN
L b. IF MULTIPLE BIRTH CHILD WAS
3 0 5 6 7 9 9
D 5a. TYPE OF BIRTH
X
____ 1 Single ______ 2 Twin
______ 3 Triplets, etc.
____ 1 First ______ 2 Second
______ 3 Others, Specity __________
48
d. WEIGTH AT ORDER
C. BIRTH ORDER (Order of this birt to
2
SEVEN previous live birth including fetal death
(First, Second, Third, etc.) 1600
___________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME VIVIAN ALI BARING
1 0 7 1 9 2 2
7. CITIZENSHIP 8 . RELIGION
M FILIPINO ROMAN CATHOLIC 51
O 9a. Total number of b. No. of children still c. No. of children
1 7 5 6 5
T children born
07 living including born alive but
H
alive ______________ 07
this birth _____________ 00
are now dead ___________
E 10. OCCUPATION 11. Age at the time of this 61
R birth (completed year) 1
HOUSE WIFE 36
____________years
12. RESIDENCE (House No. St. Barangay) (City/Municipality) (Province) 62 64
40 PRK,4B BALAGTAS ST. LOWER BICUTAN TAGUIG CITY METRO MANILA 0 2 1 9 4 8
13. NAME (First) (Middle) (Last)
F
A EUGENE DUMRIQUE AGAMATA 68 69
T 14. CITIZENSHIP 15 . RELIGION 0 1 1
H FILIPINO ROMAN CATHOLIC
E 16. OCCUPATION 17. Age at the time of this
R birth (completed year) 70 72 74
EMPLOYEE 37
____________years

18. DATE AND PLACE OF MARRIAGE OF PARENTS (If not married, accomplish Affidavit of 0 2 0 2 0 0
acknowledge/ Admission of Paternity at the back.)
OCTOBER 19, 1992 TAGUIG CITY METRO MANILA
19a. ATTENDANT 76 79
7 2 6 2 8
______ 1 Physician _______2 Nurse X
_______3 Midwife
_______Hilot (Tranditinal Birth Attendant) _______ 5 Others (Specify)
19b. CERTIFICATION OF BIRTH
I hereby that l attended the birth of the child who was born alive at _____________________o'clock
81
am/pm on the date of birth specified above. 5 6 0 6 0
Signature _____________________________________ 40 PRK, 4V BALAGTAS
Address ____________________________________
DANICA P. RICO
Name in Print __________________________________ ST. LOWER BICUTAN
__________________________________________
86 87
MIDWIFE
Title or Position _________________________________ OCTOBER 22, 2010
Date ______________________________________
20. IMFORMANT 1 1
40 PRK,4B BALAGTAS ST. LOWER
Signature _____________________________________ Address ____________________________________ 88 91
VIVIAN B. AGAMATA BICUTAN TAGUIG CITY METRO MANILA
Name in Print __________________________________ __________________________________________
OCTOBER 22, 2010
9 9 9 3 7
MOTHER
Relationship to the Child ________________________ Date ______________________________________

21. PREPARED BY 22. REGISTERED AT THE OFFICE OF

THE CIVIL REGISTRAR 93

Signature _____________________________________ Signature _________________________________

1
HAZEL D. ABAAWA
Name in Print _________________________________ BRYAN Q. VELAZQUEZ
Name in Print______________________________
Title or Position CITY CIVIL REGISTRAR
_______________________________ MUNICIPAL CIVIL OFFICER
Titke in Position___________________________
94
OCTOBER 30, 2010 OCTOBER 30, 2010
Date __________________________________________ Date ______________________________________
3

06481-H6-005FSA-00236-B|002
BEST POSSIBLE IMAGE
CLAIRE DENNIS S. MAPA, Ph. D.
National Statistician and Civil Registrar General
T005084810050020910302010002 Philippine Statistics Authority
NL7D00589445