Académique Documents
Professionnel Documents
Culture Documents
102
accomplished in quadruplicate)
(revised January 1993)
(To be
REMARKS/ANNOTATION
and 19a)
Registry
no.
Province
City/Municipality
1.
NAME
(last)
(First)
(middle)
TO BE FILLED UP AT THE
SEX
2.
C
H
I
L
D
1 Male
Female
4. PLACE OF
_2
3. DATE OF BIRTH
(year)
(day)
( Name of Hospital/clinic/institution/
House No., Street, Barangay)
BIRTH
(city/municipality)
_1 First
Single
2 Twin
c. BIRTH ORDER
41
(province)
48
d. WEIGHT AT BIRTH
_grams
fetal deaths
including this delivery)
2 Second
_3 others, Specify
3 Triple, etc
(first,
M
O
T
H
E
R
(month)
6. MAIDEN
NAME
(First)
(middle)
49
c.
11.
10. OCCUPATION
No. of Children
born alive 56
but
are now dead:
61
Age at the
time
Of this
birth:
years
12. RESIDENCE
(last)
50
62
(City/Municipality)
64
(Province)
F
A
T
13. NAME
(last)
(First)
(middle)
14. CITIZENSHIP
RELIGION
H
E
17.
70
74
15.
72
year
s
U
16. OCCUPATION
Age at the time
76
Of this birth:
79
19a. ATTENDANT
U
U
1 Physician
Nurse
Midwife
Others (Specify)
Address
Name in Print
Title of
Position
oclock
86
Date
87
20.
INFORMANT
Signature
Address
88
Print
94
Name in
91
Title of Position
21.
PREPARED BY
Signature
Name in Print
Title of Position
Date
Date
22.
RECEIVED
Signature
Name in Print
Title of Position
Date
93
AT THE
OFFICE OF
THE CIVIL REGISTER
( Signature of Father)
( Signature of Father)
Communi
ty Tax No.
Date
Issued _
Place
Issued
Date Issued
Place Issued
U
SUBSCRIBED AND
SWORN to before me this
at
d
a
y
,
, Philippines.
o
f
U
( Name in Print)
( Address)
REGISTRATION OF BIRTH
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
of my birth / of the birth of
2. That I/he/she was born
a
on
t
3. That I/he/she was
attended at birth by
who resides
at
.
.
a
t
(Signature of Affiant)
Community Tax No
Date Issued
Place Issued
SUBSCRIBED AND SWORN to before me this
,
at
, Philippines.
( Name in Print)
( Address)
day of