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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)

Registry
no.

Province

FOR OCRG USE ONLY:

Population Reference No.

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)

b. IF MULTIPLE BIRTH, CHILD WAS

5a. TYPE OF BIRTH


1

_1 First

Single

2 Twin

c. BIRTH ORDER

41

(province)

48

d. WEIGHT AT BIRTH

(live births and

_grams

fetal deaths
including this delivery)

OFFICE OF THE CIVIL


REGISTRAR

2 Second

_3 others, Specify
3 Triple, etc

(first,

second, third, etc.)

M
O
T
H
E
R

(month)

6. MAIDEN
NAME

(First)

9a. Total number of


Children born
Alive:

b. No. of Children Still


living including
this birth:

(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

(House No., Street, Barangay)

(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

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

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

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)

Communi
ty Tax No.
Date
Issued _
Place
Issued

Community Tax No.

Date Issued
Place Issued
U

SUBSCRIBED AND
SWORN to before me this
at

d
a
y

,
, Philippines.

o
f
U

(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
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

for the delayed registration

who resides
at

.
.

4. That I/he/she is a citizen


of
5. That my/his/her parents
were
married on

a
t

Not Married but was


acknowledge by my/his/her father whose name is
.
6. That the reason for the delay in
.
registering my/his/her birth was due to
7. That a copy of my/his/her birth
.
.
certificate is needed for the purpose of
of the
8.
(For the applicant only) That
said
I am married to
person.
( For the
Father/mother/guardian) That I
am the
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