Escolar Documentos
Profissional Documentos
Cultura Documentos
102
accomplished in quadruplicate)
(revised January 1993)
(To be
REMARKS/ANNOTATION
and 19a)
Province
METRO MANILA
City/Municipality
C
H
I
L
D
Female
94-1481
(First)
JERICK
CERDAA
SEX
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
THE CIVIL
REGISTRAR
(city/municipality)
_grams
3.180
fetal deaths
including this delivery)
(first,
M
O
T
H
E
R
6. MAIDEN
NAME
JENNIFER
7. CITIZENSHIP
FILIPINO
(First)
(middle)
SOLANO
CABRERA
8. RELIGION
c.
11.
17
12. RESIDENCE
(last)
50
CATHOLIC
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)
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
19a. ATTENDANT
U
U
1 Physician
Nurse
Midwife
Others (Specify)
oclock
Address
PANFILO B. SOLANO JR, MD
20.
INFORMANT
86
87
LIC #056248
Date
Signature
U
Name in Print
VALENZUELA BULACAN
JENNIFER CARDIAS
Title of Position
21.
91
PREPARED BY
Signature
Name in Print
Title of Position
Date
88
Address
22.
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
( Signature of Father)
( Signature of Father)
Commun
ity Tax
No.
Date
Issued _
Place
Issued
Date Issued
Place Issued
SUBSCRIBED
AND SWORN to before me
this
at
d
U
,
, Philippines.
( 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 for the delayed
registration of my birth / of the birth of
2.
born
I/he
U
3
.
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
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.
day of