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.)
MISAMIS OCCIDENTAL Registry No.
Province
City/Municipality OZAMIZ CITY 96-2211
1. NAME (First) (Middle) (Last) For OCRG USE ONLY.
Pupolation Reference No.
SAVANNAH SHINE ALYCIA ANG HEMSWORTH
2. SEX 3. DATE OF BIRTH (Day) (Month) (Year)
____ 1 Male ______
X 2 Female 22 NOV 1996 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
SINACABAN MISAMIS OCCIDENTAL
L b. IF MULTIPLE BIRTH CHILD WAS 0 2 0 3 2 0 1
D 5a. TYPE OF BIRTH
X 1 Single
____ ______ 2 Twin ____ 1 First ______ 2 Second
______ 3 Triplets, etc. ______ 3 Others, Specity __________
48
d. WEIGTH AT ORDER
C. BIRTH ORDER (Order of this birt to
FIRST previous live birth including fetal death
3
(First, Second, Third, etc.)
2800 grams
___________
49 50
6. MAIDEN (First) (Middle) (Last)
NAME SUSANA DEVINE TAN ANG
1 1 0 4 1 0 0
7. CITIZENSHIP 8 . RELIGION
FILIPINO CHRISTIAN BORN AGAIN 51
M
O 9a. Total number of b. No. of children still c. No. of children
1 1 9 9 3
T children born
01
alive ______________
living including born alive but
00
H 01
this birth _____________ are now dead ___________
E 10. OCCUPATION 11. Age at the time of this 61
R
BUSINESS WOMAN
birth (completed year) 4
24
____________years
12. RESIDENCE (House No. St. Barangay) (City/Municipality) (Province) 62 64
PAROJINOG ST. CORNER CEBEDO AGUADA OZAMIZ CITY 0 2 1 9 4 0
13. NAME (First) (Middle) (Last)
F
JAMES THOMAS HEMSWORTH 68 69
A
T 14. CITIZENSHIP 15 . RELIGION 0 1 0
H US BORN AGAIN
E 16. OCCUPATION 17. Age at the time of this
R birth (completed year) 70 72 74
US NAVY 28
____________years

18. DATE AND PLACE OF MARRIAGE OF PARENTS (If not married, accomplish Affidavit of 0 2 0 2 8 9
acknowledge/ Admission of Paternity at the back.)

NOT MARRIED

19a. ATTENDANT 76 79
______ 1 Physician _______2 Nurse X Midwife
_______3 7 2 6 2 1
_______Hilot (Tranditinal Birth Attendant) _______ 5 Others (Specify)

19b. CERTIFICATION OF BIRTH

4:10 AM
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 _____________________________________ SINACABAN MISAMIS
Address ____________________________________
Name in Print __________________________________
DIANNA A. TOLENTINO __________________________________________
OCCIDENTAL 86 87
Title or Position _________________________________
RHU MIDWIFE NOVEMBER 22, 1996
Date ______________________________________
20. IMFORMANT 1 1
Signature _____________________________________ PAROJINOG ST. CORNER
Address ____________________________________ 88 91
SUSANA DEVINE T. ANG
Name in Print __________________________________ CEBEDO AGUADA OZAMIZ CITY
__________________________________________ 9 9 9 3 7
Relationship to the Child ________________________
MOTHER Date ______________________________________
NOVEMBER 22, 1996

21. PREPARED BY 22. REGISTERED AT THE OFFICE OF

THE CIVIL REGISTRAR 93

Signature _____________________________________ Signature _________________________________

1
Name in Print _________________________________
GRANDO P. GOMEZ Name in Print______________________________
DAINEL D. DAVID
Title or Position _______________________________
REGISTRATION OFFICER III RECORDS OFFICER
Titke in Position___________________________
NOVEMBER 30, 1996 94
Date __________________________________________
NOVEMBER 30, 1996 Date ______________________________________
3

06481-H6-989BA19-00236-B|002 BReN
BEST POSSIBLE IMAGE 05806-B00G201-3
CLAIRE DENNIS S. MAPA, Ph. D.
National Statistician and Civil Registrar General
Documentary Philippine Statistics Authority
T00508481005002360911301996700 Stamp Tax Paid
2 L7D00020520244
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