Municipal Form No.
102 (To be accomplished in quadruplicate using black ink)
(Revised January 2007) Republic of the Philippines
OFFICE OF THE CIVIL REGISTRAR GENERAL
CERTIFICATE OF LIVE BIRTH
Province Registry No.
CEBU
City/Municipality DALAGUETE
l. NAME (First) (Middle) (Last)
AVERY ISHA POMBUENA ASENJO
2. SEX (Male/ Female) 3. DATE OF (Day) (Month) (Year)
FEMALE BIRTH 12 APRIL 2024
4. PLACE OF (Name of Hospital/Clinic/lnstitution/ (City/Municipality) (Province)
House No.,
BIRTH St.: Barangay)
c SITIO TUBOD, OBONG DALAGUETE CEBU
5a. TYPE OF BIRTH 5b. IFMULTIPLEBIRTH,CHILDWAS 5c. BIRTH ORDER
births induding fetal death)
previous live 6. WEIGHTATBIRTH
(Single, Twin,Triplet, etc.) SINGLE (First, Second, Third, etc.) (First, Second, Third, etc.) SECOND
2100
NOT APPLICABLE
D grams
7. MAIDEN (First) (Middle) (Last)
NAME TRICIA ELENA ARGALLON POMBUENA
8. CITIZENSHIP 9. RELIGION/RELIGIOUS SECT
FILIPINO ROMAN CATHOLIC
10a. Total number of children 10b. No. of children still IOC. No. of children born 11. OCCUPATION 12 AGE at the time of this
born alive living including this birth alive but are now birth (completed years)
dead
2 2 HOUSEWIFE 19
NOT
APPLICABLE
13. RESIDENCE (House No., St., ±rangay) (City[Municipality) (Province) (Country)
SITIO TUBOD, OBONG DALAGUETE CEBU PHILIPPINES
14. NAME (First) (Middle) (Last)
ROSALIO ZAMORA ASENJO
15. CITIZENSHIP16. RELIGION/RELIGIOUSSECT 17. OCCUPATION 18. AGE at the time of this
birth (completed years)
FILIPINOROMAN CATHOLIC FARMER 27
19, RESIDENCE (House Barangay) (City/Municipality) (Province) (Country)
SITIO TUBOD, OBONG DALAGUETE CEBU PHILIPPINES
MARRIAGE OF PARENTS (If not married, accomplish Affidavit of Acknowledgement/Admission of Paternity at the back.)
Oa. DATE (Month) (Day) (Y ear) 20b. PLACE (City / Municipality) (Province) (Country)
NOT MARRIED NOT APPLICABLE
la.ATTENDANT
1 physician 2 Nurse 3 Midwife x 4 Hilot (Traditional Birth Attendant) 5 Others (Specify)
21 b. CERTIFICATION OF ATTENDANT AT BIRTH (Physician, Nurse, Midwife, Traditional Birth etc.)
I hereby certify that I attended the birth of the child who was born alive at 2:07 PM am/pm on the date of bilth specified above.
Signature Address
ZOSIMO B. DEBUAYAN SITIO TUBOD, OBONG, DALAGUETE, CEBU
Name in Print
TRAINED HILOT APRIL 18, 2024
Title or Position
Date
22. CERTIFICATION OF INFORMANT 23. PREPARED BY
I herebycertify
correct to
that all information supplied are true and
own knowledgeand belief.
Signature
Name in
Relationship
Address A
PRIL 18, 2024
Date
24. RECEIVED BY 25. REGISTERED BY THE CIVIL REGISTRAR
Signature Signature
ROMAR JACINTO D. ANORE ESTELITA B. CEBALLOS
Name in Print Name in Print
MUNICIPAL REGISTRAR, OIC
BARANGAY SECRETARY Title or Position
Tlt;e or Position APRIL 19, 2024
Date
APRIL 18, 2024
Date
REMARKS/ANNOTATIONS (For LCRO/OCRG Use only)
