Municipal Form No.
102 (To be accomplished in
quadruplicate)
(Revised January 1993)
REMARKS/ANNOTATION
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 ZAMBOANGA DEL SUR Registry
PAGADIAN CITY
No. City/Municipality
2023-01112
1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:
Population reference No.
MAXXIMUS CAESAR DE VEGA CINCO
2. SEX 3. DATE OF BIRTH (day) (month)
(year) 1 Male 2 Female
08 JUNE 2023
4.
C PLACE OF (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) TO BE FILLED UP AT
H BIRTH House No., Street, Barangay)
THE OFFICE OF THE
CIVIL REGISTRAR
I MENDERO HOSPITAL, PAGADIAN CITY
L 41
D 5a. TYPE OF BIRTH b. IF MULTIPLE BIRTH, CHILD WAS
1 Single 2 1 First 2 Second
Twin 3 Others, Specify
3 Triplet. Etc. 48
c. BIRTH ORDER (live births and fetal deaths
d. WEIGHT AT BIRTH
including this
First delivery) 3400 grams
(first, second, third,
etc.)
6. MAIDEN (First) (Middle) 49 50
(Last) NAME
CASSANDRA SUZZETTE IMPERIAL DE VEGA
7. CITIZENSHIP 8. RELIGION
M FILIPINO ROMAN CATHOLIC 56
O
9a. Total number of b. No. of Children c. No. of children
T
still born alive but
children born living including1 0
H
alive: 1 this birth: are now dead:
E 61
10. OCCUPATION 11. Age at the
R time of this
HOUSEWIFE birth: 2
3 years
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province) 62 64
LA SUERTE, PAGADIAN CITY
13. NAME (First) (Middle) (Last)
F ANTHONY DYLAN PATIS CINCO 68 69
A 14. CITIZENSHIP 15. RELIGION
T FILIPINO
H ROMAN 70 72 74
E CATHOLIC
R 16. OCCUPATION 17. Age at the
time of this
BUSINESSMAN birth: 2
5 years
76 79
18. DATE AND PLACE OF MARRIAGE OF PARENTS (If not married, accomplish
Affidavit of Acknowledgement/Admission of Paternity at the back.)
25 December 2022 – San Jose Parish Church, Pagadian City
19a. ATTENDANT 81
1 Physician 2 Nurse 3 Midwife
4 Hilot (traditional Midwife) 5 Others (Specify)
19b. CERTIFICATION OF BIRTH
9:30
I hereby certify that I attended the birth of the child who was born alive at
PM 86 87
o’clock am/pm on the date stated above.
Signature Address Mendero Hospital
Dr. Guadalofe Amriso
Name in Print Pagadian City
Title or Position Obstetrician-Gynecologist Date June 8, 2023
88 91
20. INFORMANT
Signature Address La Suerte, Pagadian
93
City
Zamboanga del Sur
Name in Print Anthony Dylan P. Cinco
Relationship to the child Date
Fathe June 8, 2023
21.PREPARED BY r 22.RECEIVED AT THE OFFICE
OF THE CIVIL REGISTRAR
94
Signature
Signature
Name in PrintFebie C. Dante Name in PrintRosielyn D.
Brooks
Local Civil Registrar
Title or Position
Date
Cler Title or Position
June 9, 2023
June 9, 2023
k Date
For this before 3 August 1988/on or after 3 August 1998
AFFIDAVIT OF ACKNOWLEDGEMENT/ADMISSION OF PATERNITY
Well, and
parents/parent of the child mentioned in this Certificate of live Birth, do hereby solemnly swear that the information contained herein are
true and correct to the best of our/my knowledge and belief.
(Signature of Father) (Signature of Mother)
Community Tax No. Community Tax No.
Date Issued Date Issued
Place Issued Place Issued
SUBSCRIBED AND SWORN to before me this day of ,
at , Philippines.
(Signature of Administering Officer) (Title/Designation)
(Name in Print) (Address)
Not applicable for births before 27 February 1931
AFFIDAVIT FOR DELAYED REGISTRATION OF BIRTH
(Either the person himself if 18 years old or over, or father/mother/guardian may accomplish this affidavit.)
I, , of 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. That I/he/she was born on at .
3. That I/he/she was attended at birth by who resides at
.
4. That I/he/she is citizen of .
5. That my/his/her parents were married on at
.
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
.
8. (For the applicant only) That I am married to .
(For the father/mother/guardian) That I am the of the said person.
(Signature of Affiant)
Community Tax No.
Date Issued
Place Issued
SUBSCRIBED AND SWORN to before me this day of ,
at , Philippines.
(Signature of Administering Officer) (Title/Designation)
(Name in Print) (Address)
