Page 1 of 1, 1 Copyy
STA
1STIc
N E
S4
(Copyfor OCRG)
MunicpalFom No. 102
RovisedJanuary 1933)
(To be accomplished In quadruplicata)
REMARKS/ANNOTATION
Republc of the Phlippines
OFFICE OF THE CIMIL REGISTRAR GENERAL
CERTIFICATE OF LIVE BIRTH
( F out oompletely, aocurstely and legibly. Usa Ink or ypewrlter.
Provlnce
Registry No.
HAKATI
City/Munlclpality
1. NAME
oo2-2S
(First)
BREXON RARTL
(Mddie)
AAGOG
2. SEX
SORTARO
3. DATE OF BIRTH
Mate
day)
month) rea
C5 Anguet
Female
C4. PLACE OF (Nameof Hospital/Clinio/mstitution/
(City/Municipality)
House No., Street, Barangay)
ST CLARES MEDICAI.
CENTER,Peleran Haltoti City
1 Sing
1 Fret
FiNt)
(Mddle)
BIC0
T
8. REIGION
41ipino
b. No.at childon sl
ohildren bom
ting including
alive
E10. OCCUPATION
Second
Last)
AT2COG
7. CITIZENSHP
Totai number ot
2
d.WEIGHT AT BIRTH
2410
grams
tnckuding this delivery)
PrOF (irat,
aecond, thlrd, atG
NAME
THE CHVIL
REGISTRAR
3Others, Speltly
BIRTH QRDER (lfve birthe andfetal de aths
MAIDEN
TO BE FILLED UP AT THE
OFFICE F
b.IF MULTIPLE BIRTH, CHILD WAS
2 Twin
Tripiet, ac.
.
0E
Provinoe)
BIRTH
Sa. TYPE OF BIRTH
For OCRG USE ONL¥
Populatlon Heference No.
Be Cataolic
No.of children
1
born allve but
thia birih:
Me now aead: -
11.
Houaeife
Age at the time
ofthis birth:
yeas
12. RESIDENCE (House No., Street, Barangay)
23-B Lucban St. , Paaey Clty
F
13. NAME
T 14.
Fire)
(City/Municipality)
(PrOvinca)
(Middle)
BEWIE
CITIZENSHIP
ilipino
JACOBO
SOT ARD
REIGloN
15.
16. OCCUPATION
17.
B
Catholic
Age at the tm
ofthis o
20
yeara
18. DATE AND PLACE OF MARRIAGE OF PARENTS nat maried, acoomplah Amidavit of
Acknowiedgment/Admission of Paternity atthe back.)
Saptembor 28, 2000
2 Frenciseo St, nPEV,las Piäan City
19a. ATTENDANT
Physician
4
Nurse
Hilot (Traditional Midwifo)
3
5 Cthere (Specity)
19h. CERTIFICATION OF BIRTH
Ihereby certity that I attended thapinh af the chid who was bom alve at
Midwife
EeHa ocdock
am/pm on the dais siated above.
Address L3 Dian 8t,Palenen
Saneture
Name in Print
BDI YOGRONTO,kD
Tiltie orPostliorYcia
Addresplteti Cit
Date
0, 2002
0300
20. INFORMANT
Sgnature
Nare in Print
Address -
A 903TANO
Feletonshipo techildFothor
21. FREPARED BY
233-B Lucban St
Paany Gity
Au 09, 2C02
Dats
22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTAMA
Sigrature
Signature
Piadodicul Hacorda 0trio
Tise or Poukion
Tide or Pasiltion
Daie.
Lals
tNane is
Aug.
09, 202
07226-G5-009MCO-01120-BI001
Narne in Prnt-
DELTA ETABUTAFE
REGISTRATION OFFICER-Z
Y6 AUG 2002
BEST POSSIBLE IMAGE
BReN
07602-B02Q50C-1
TO09072260090112010142019001
Stamp Tax Paid
UN500331586
94
Documentary
CLAIRE DENNIS S. MAPA, Ph. D.
National Statistician and Civil Registrar General
Philippine Statistics Authorily