Municipal Form No.

102
accomplished in quadruplicate)
(revised January 1993)

(To be

REMARKS/ANNOTATION

Republic of the Philippines

OFFICE OF THE CIVIL REGISTER 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

METRO MANILA

City/Municipality

C
H
I
L
D

Female

Population Reference No.

94-1481

(First)

JERICK

CERDAA
SEX

FOR OCRG USE ONLY:

750- A94EMKEY

KALOOKAN CITY

1.
NAME
(last)

2.

Registry
no.

(middle)
TO BE FILLED UP AT THE

CABRERA

1 Male

3. DATE OF BIRTH
(year)

_2

4. PLACE OF

(day)

( Name of Hospital/clinic/institution/
House No., Street, Barangay)

BIRTH

(month)

_1 First

2 Twin

Single

1ST

2 Second

_3 others, Specify

48

d. WEIGHT AT BIRTH

3 Triple, etc

c. BIRTH ORDER

(province)
41

b. IF MULTIPLE BIRTH, CHILD WAS

THE CIVIL
REGISTRAR

(city/municipality)

#42 FILI ST. KALOOKAN CITY METRO MANILA

5a. TYPE OF BIRTH

21 MARCH 1994 OFFICE OF

_grams

3.180

(live births and

fetal deaths
including this delivery)

(first,

second, third, etc.)

M
O
T
H
E
R

6. MAIDEN
NAME

JENNIFER

7. CITIZENSHIP

FILIPINO

(First)

9a. Total number of

Children born
Alive:
1

(middle)

SOLANO

CABRERA
8. RELIGION

c.

11.

17

12. RESIDENCE

(House No., Street, Barangay)

(last)
50

CATHOLIC

b. No. of Children Still

living including
this birth:
1

10. OCCUPATION
HOUSEKEEPER

49

No. of Children
born alive 56
but
are now dead:

61

Age at the
time
Of this
birth:

years

62

(City/Municipality)

64

(Province)

Q-4 789 KAMAGONG ST.

BULACAN

13. NAME
(last)

VALENZUELA

(First)

RICRDO

A
T

14. CITIZENSHIP
RELIGION
CATHOLIC

(middle)

NICOLAS

CERDNAS

FILIPINO

70
74

15.

72

year
s
U

H
E
17.

16. OCCUPATION
Age at the time

BUSINESSMAN

76

Of this birth: 18

79

18. DATE AND PLACE OF MARRIAGE OF PARENTS

( If not married, accomplish affidavit of

Acknowledgement/ Admission of Paternity at the back)

19a. ATTENDANT
U
U

1 Physician

Nurse

Midwife

4 Hilot (Traditional Midwife)

Others (Specify)

19b. CERTIFICATION OF BIRTH

I hereby certify that I attended the birth of the child who was born alive at81
am/pm on the date stated above.
Signature
Name in Print
Title of
Position
U

oclock

Address
PANFILO B. SOLANO JR, MD
20.
INFORMANT

101 KALOOKAN CITY

86

87

LIC #056248
Date
Signature
U

Name in Print

VALENZUELA BULACAN

JENNIFER CARDIAS

Title of Position
21.

91

Q-4 789 KAMAGONG ST.

Date 25 MARCH 1994

PREPARED BY

Signature
Name in Print
Title of Position
Date

88

Address

22.

MARLENE JOY J. SOLANO

SECRETARIAT
28 MARCH 1994

RECEIVED

Signature
Name in Print
Title of Position
Date

93
AT THE
OFFICE OF
THE CIVIL REGISTER
94

ERLINA C. NAME
RECEIVING OFFICER
05 APRIL 1994

For births before 3 August 1988/on or after 3 August 1988

AFFIDAVIT OF
ACKNOWLEDGMENT/ADMISSION OF PATERNITY
and
We/ I,
Parents /parent of the child mentioned in this Certificate of Live Birth do hereby
solemnly swear that the information contained herein and
true and correct to the best of our/my knowledge and belief.
U

( Signature of Father)
( Signature of Father)

Commun
ity Tax
No.
Date
Issued _
Place
Issued

Community Tax No.

Date Issued
Place Issued

SUBSCRIBED
AND SWORN to before me
this
at

d
U

,
, Philippines.

(Signature of Administering Officer)

( Title/ Designation)
U

( Name in Print)
( Address)

Not applicable for births before 27 February 1931

REGISTRATION OF BIRTH

AFFIDAVIT FOR DELAYED

( Either the person himself if 18 years old or over, or

father/mother/guardian may accomplish this affidavit)

I,
, 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.
born
I/he
U

3
.

That I/he/she was attended

at birth by

a
t

4. That I/he/she is a
citizen of
5. That my/his/her parents
were
married on

who resides
at
U

a
t

Not Married but

was acknowledge by my/his/her father whose name is
U

6. That the reason for the delay in

registering my/his/her birth was due to
U
U

7. That a copy of my/his/her birth

certificate is needed for the purpose
of
U

8.
(For the applicant only)
That I am married to
( For the
Father/mother/guardian) That
I am the

of the
said
person.
U

(Signature of Affiant)

Community Tax No
Date Issued
Place Issued
SUBSCRIBED AND SWORN to before me this
,
at
, Philippines.

(Signature of Administering Office)

(Title/ Designation)
( Name in Print)
( Address)

day of