Republic Of The Philippines Certificate Of Live Birth
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2Municipal Form No. 102
(To be accomplished in quadruplicate)
REMARKS/ANNOTATION
(Revised January 1993)
Republic of the Philippines
OFFICE OF THE CIVIL REGISTRAR 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 _________________________________________
Registry No.
City/Municipality ___________________________________
FOR OCRG USE ONLY:
1. NAME
(First)
(Middle)
(Last)
Population reference No.
2. SEX
3. DATE OF BIRTH
(day)
(month) (year)
______ 1 Male _______ 2 Female
TO BE FILLED UP AT THE
C
4. PLACE OF
OFFICE OF THE CIVIL
(Name of Hospital/Clinic/Institution/
(City/Municipality)
(Province)
H
REGISTRAR
BIRTH
House No., Street, Barangay)
I
41
L
D
5a. TYPE OF BIRTH
b.
IF MULTIPLE BIRTH, CHILD WAS
_____ 1 Single
______ 2
Twin
_____ 1 First
______ 2
Second
______ 3
Triplet. Etc.
______ 3
Others, Specify _____________
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c. BIRTH ORDER
d. WEIGHT AT BIRTH
(live births and fetal deaths
including this delivery)
_____________ (first, second, third, etc.)
________________ grams
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50
6. MAIDEN
(First)
(Middle)
(Last)
NAME
7.
CITIZENSHIP
8. RELIGION
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M
O
9a.
b.
c. No. of children
Total number of
No. of Children still
T
children born
living including
born alive but
H
alive: _________
this birth: _________
are now dead: _________
E
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10. OCCUPATION
11.
R
Age at the time
of this birth:
_______years
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12. RESIDENCE
(House No., Street, Barangay)
(City/Municipality)
(Province)
13. NAME
(First)
(Middle)
(Last)
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69
F
A
14. CITIZENSHIP
15. RELIGION
T
H
70
72
74
E
R
16.
OCCUPATION
17.
Age at the time
of this birth:
_______years
76
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18. DATE AND PLACE OF MARRIAGE OF PARENTS
(If not married, accomplish Affidavit of
Acknowledgement/Admission of Paternity at the back.)
_______________________________________________________________________________________________
19a. ATTENDANT
_____1 Physician
______ 2 Nurse
______ 3 Midwife
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_____4 Hilot (traditional Midwife)
______ 5 Others (Specify)
_______________________________________________________________________________________________
19b. CERTIFICATION OF BIRTH
I hereby certify that I attended the birth of the child who was born alive at ______________o’clock
am/pm on the date stated above.
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Signature ______________________________
Address ______________________________
Name in Print ___________________________
_____________________________________
Title or Position _________________________
Date _________________________________
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91
_______________________________________________________________________________________________
20. INFORMANT
Signature ______________________________
Address ______________________________
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Name in Print ___________________________
_____________________________________
Relationship to the child ___________________
Date ________________________________
_______________________________________________________________________________________________
21. PREPARED BY
22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
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Signature ______________________________
Signature _____________________________
Name in Print ___________________________
Name in Print __________________________
Title or Position _________________________
Title or Position ________________________
Date __________________________________
Date _________________________________
_______________________________________________________________________________________________
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