Page , 1 of 1, 1 Copy

Copy for OCRG

Municipal Form No. 102 To be accomplished In quadruplicate REMARK/ANNOTATION

Registed January 2010
Republic of the Philippines
OFFICE OF THE CIVIL REGISTRAR GENERAL DELAYED REGISTRATION
CERTIFICATE OF LIVE BIRTH
(Fill out completely, accuratelyand legitby, Use ink or typewriter
Please X before appropreses answer items 2, 5a, 5b, and 19a.)

Province CEBU Registry No.

City/Municipality MANDAUE 2002-740
1. NAME (First) (Middle) (Last) For OCRG USE ONLY.
Pupolation Reference No.
JULIANNE MAE ANTIGUA DUNGOG
2. SEX 3. DATE OF BIRTH (Day) (Month) (Year)
X
____ 1 Male ______ 2 Famale 03 MAY 1997 TO BE FILLED-UP OF THE
OFFICE OF THE CIVIL
C 4. PLACE OF (Name of Hospital/Clinic/Institution (City/Municipality) (Province) REGISTRAR
H BIRTH
House No. St, Barangay)

I 41
L
LOOC MANDAUE CITY 3 0 5 6 7 9 9
b. IF MULTIPLE BIRTH CHILD WAS
D 5a. TYPE OF BIRTH
X
____ 1 Single ______ 2 Twin X
____ 1 First ______ 2 Second
______ 3 Others, Specity __________
______ 3 Triplets, etc. 48
d. WEIGTH AT ORDER
C. BIRTH ORDER (Order of this birt to
2
FIRST previous live birth including fetal death
(First, Second, Third, etc.) 7.8lbs
___________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME RAQUEL DIEZ ANTIGUA 1 0 7 1 9 2 2
7. CITIZENSHIP 8 . RELIGION
M FILIPINO ROMAN CATHOLIC 51
O 9a. Total number of b. No. of children still c. No. of children
1 7 5 6 5
T children born
01 living including born alive but
H
alive ______________ 01
this birth _____________ 00
are now dead ___________
E 10. OCCUPATION 11. Age at the time of this 61
R birth (completed year) 1
HOUSE WIFE 27
____________years
12. RESIDENCE (House No. St. Barangay) (City/Municipality) (Province) 62 64
LOOC MANDAUE CITY 0 2 1 9 4 8
13. NAME (First) (Middle) (Last)
F
A JERRY AMORES DUNGOG 68 69
T 14. CITIZENSHIP 15 . RELIGION 0 1 1
H FILIPINO ROMAN CATHOLIC
E 16. OCCUPATION 17. Age at the time of this
R birth (completed year) 70 72 74
HOTELIER 26
____________years

18. DATE AND PLACE OF MARRIAGE OF PARENTS (If not married, accomplish Affidavit of 0 2 0 2 0 0
acknowledge/ Admission of Paternity at the back.)
MARRIED
19a. ATTENDANT 76 79
______ 1 Physician _______2 Nurse X Midwife
_______3 7 2 6 2 8
_______Hilot (Tranditinal Birth Attendant) _______ 5 Others (Specify)

19b. CERTIFICATION OF BIRTH

12:00 PM
I hereby that l attended the birth of the child who was born alive at _____________________o'clock
81
am/pm on the date of birth specified above. 5 6 0 6 0
Signature _____________________________________ Address ____________________________________
FRANCESCA T. REYES
Name in Print __________________________________ LOOC MANDAUE CITY CEBU
__________________________________________
86 87
HILOT
Title or Position _________________________________ MAY 03, 1997
Date ______________________________________
20. IMFORMANT 1 1
Signature _____________________________________ Address ____________________________________ 88 91
RAQUEL D. ANTIGUA
Name in Print __________________________________ LOOC MANDAUE CITY
__________________________________________ 9 9 9 3 7
MOTHER
Relationship to the Child ________________________ MAY 03, 1997
Date ______________________________________

21. PREPARED BY 22. REGISTERED AT THE OFFICE OF

THE CIVIL REGISTRAR 93

Signature _____________________________________ Signature _________________________________

1
DANICA W. RAMOS
Name in Print _________________________________ EMELDA P. SANTOS
Name in Print______________________________
Title or Position COMMUNITY MUNICIPAL II
_______________________________ CIVIL REGISTRAR
Titke in Position___________________________
94
MAY 05, 1997 MAY 05, 1997
Date __________________________________________ Date ______________________________________
3

06481-H6-005FSA-00236-B|002
BEST POSSIBLE IMAGE
CLAIRE DENNIS S. MAPA, Ph. D.
National Statistician and Civil Registrar General
T0050848100500236050519977002 Philippine Statistics Authority
NL7D00589445