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 _________________________________________ Registry No.

City/Municipality ___________________________________

1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:

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 (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) OFFICE OF THE CIVIL
H BIRTH House No., Street, Barangay) REGISTRAR
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 _____________
48

c. BIRTH ORDER (live births and fetal deaths d. WEIGHT AT BIRTH

including this delivery)
_____________ (first, second, third, etc.) ________________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME

7. CITIZENSHIP 8. RELIGION
56
M
O
T Name:9a.
Suzanne
Donald
Stephanie
Michelle
Richard
Janet
Sheri
John
Elijah
David Karen
Danielle
Shannon
Alison
Kyle
Total Lauren
Darryl
Elizabeth
Laura
Thomas
Paul
Mckee
numberMurphy Johnsonb.
Roberts
Collins
ofJohnson
Walker
Doyle
Martinez No. of Children still c. No. of children
Date of children
Birth: born
21-05-2024
24-03-2025
30-01-2024
14-05-2024
05-02-2025
25-07-2024
19-01-2024
21-03-2025
31-08-2024
17-03-2025 living including born alive but
H alive: _________ this birth: _________ are now dead: _________
E Sex: Male
Female 61
R Place 10. OCCUPATION
of Birth: 26496
1631
504
2017
26263
53586
9668
775
65026
288 Angela
Johnson
Diana
Latoya
James
Chelsea
Miller
Clark
Murillo
Claire
Gateway
Light
Light
Harbors,
Curve,
Land
Curve
Path
Canyon
Springs,
Suite
Apt.
Suite
Apt.
Apt.
Leblancland,
Suite
Lake
Suite
477,
North
044,
687,
274,
983,019,
Michael,
New
771,
Hunthaven,
Trujilloberg,
James,
Brennanland,
East
Lindaton,
Earltown,
Wallacebury,
Massachusetts
Steven,
New
Maryland
Iowa
Montana
Alaska
Mexico
Rhode
New 11. Age at the time
Tennessee
Illinois
Jersey
Island
of this birth:
Mother: Matthew
AdamLiBrown
Susan
Ryan
Amber
Nathan
Mary
Paul
Karen
Brittany
Hensley
Hernandez
Wright
Green
Huang
Peterson
Perry
Boone _______years
Father: Christopher
BruceKelly
Patrick
Marissa
James
Juan
John
Amy Hamilton
Wagner
Burns
Schmidt
English
Downs
LongButler
Pugh
62 64
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province)

13. NAME (First) (Middle) (Last)

68 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 79
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 81
_____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.
86 87
Signature ______________________________ Address ______________________________

Name in Print ___________________________ _____________________________________

Title or Position _________________________ Date _________________________________

_______________________________________________________________________________________________ 88 91

20. INFORMANT

Signature ______________________________ Address ______________________________

93
Name in Print ___________________________ _____________________________________

Relationship to the child ___________________ Date ________________________________

_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
94
Signature ______________________________ Signature _____________________________

Name in Print ___________________________ Name in Print __________________________

Title or Position _________________________ Title or Position ________________________

Date __________________________________ Date _________________________________
_______________________________________________________________________________________________
 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 _________________________________________ Registry No.

City/Municipality ___________________________________

1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:

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 (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) OFFICE OF THE CIVIL
H BIRTH House No., Street, Barangay) REGISTRAR
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 _____________
48

c. BIRTH ORDER (live births and fetal deaths d. WEIGHT AT BIRTH

including this delivery)
_____________ (first, second, third, etc.) ________________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME

7. CITIZENSHIP 8. RELIGION
56
M
O
T Name:9a.
Suzanne
Donald
Stephanie
Michelle
Richard
Janet
Sheri
John
Elijah
David Karen
Danielle
Shannon
Alison
Kyle
Total Lauren
Darryl
Elizabeth
Laura
Thomas
Paul
Mckee
numberMurphy Johnsonb.
Roberts
Collins
ofJohnson
Walker
Doyle
Martinez No. of Children still c. No. of children
Date of children
Birth: born
21-05-2024
24-03-2025
30-01-2024
14-05-2024
05-02-2025
25-07-2024
19-01-2024
21-03-2025
31-08-2024
17-03-2025 living including born alive but
H alive: _________ this birth: _________ are now dead: _________
E Sex: Male
Female 61
R Place 10. OCCUPATION
of Birth: 26496
1631
504
2017
26263
53586
9668
775
65026
288 Angela
Johnson
Diana
Latoya
James
Chelsea
Miller
Clark
Murillo
Claire
Gateway
Light
Light
Harbors,
Curve,
Land
Curve
Path
Canyon
Springs,
Suite
Apt.
Suite
Apt.
Apt.
Leblancland,
Suite
Lake
Suite
477,
North
044,
687,
274,
983,019,
Michael,
New
771,
Hunthaven,
Trujilloberg,
James,
Brennanland,
East
Lindaton,
Earltown,
Wallacebury,
Massachusetts
Steven,
New
Maryland
Iowa
Montana
Alaska
Mexico
Rhode
New 11. Age at the time
Tennessee
Illinois
Jersey
Island
of this birth:
Mother: Matthew
AdamLiBrown
Susan
Ryan
Amber
Nathan
Mary
Paul
Karen
Brittany
Hensley
Hernandez
Wright
Green
Huang
Peterson
Perry
Boone _______years
Father: Christopher
BruceKelly
Patrick
Marissa
James
Juan
John
Amy Hamilton
Wagner
Burns
Schmidt
English
Downs
LongButler
Pugh
62 64
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province)

13. NAME (First) (Middle) (Last)

68 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 79
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 81
_____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.
86 87
Signature ______________________________ Address ______________________________

Name in Print ___________________________ _____________________________________

Title or Position _________________________ Date _________________________________

_______________________________________________________________________________________________ 88 91

20. INFORMANT

Signature ______________________________ Address ______________________________

93
Name in Print ___________________________ _____________________________________

Relationship to the child ___________________ Date ________________________________

_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
94
Signature ______________________________ Signature _____________________________

Name in Print ___________________________ Name in Print __________________________

Title or Position _________________________ Title or Position ________________________

Date __________________________________ Date _________________________________
_______________________________________________________________________________________________
 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 _________________________________________ Registry No.

City/Municipality ___________________________________

1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:

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 (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) OFFICE OF THE CIVIL
H BIRTH House No., Street, Barangay) REGISTRAR
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 _____________
48

c. BIRTH ORDER (live births and fetal deaths d. WEIGHT AT BIRTH

including this delivery)
_____________ (first, second, third, etc.) ________________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME

7. CITIZENSHIP 8. RELIGION
56
M
O
T Name:9a.
Suzanne
Donald
Stephanie
Michelle
Richard
Janet
Sheri
John
Elijah
David Karen
Danielle
Shannon
Alison
Kyle
Total Lauren
Darryl
Elizabeth
Laura
Thomas
Paul
Mckee
numberMurphy Johnsonb.
Roberts
Collins
ofJohnson
Walker
Doyle
Martinez No. of Children still c. No. of children
Date of children
Birth: born
21-05-2024
24-03-2025
30-01-2024
14-05-2024
05-02-2025
25-07-2024
19-01-2024
21-03-2025
31-08-2024
17-03-2025 living including born alive but
H alive: _________ this birth: _________ are now dead: _________
E Sex: Male
Female 61
R Place 10. OCCUPATION
of Birth: 26496
1631
504
2017
26263
53586
9668
775
65026
288 Angela
Johnson
Diana
Latoya
James
Chelsea
Miller
Clark
Murillo
Claire
Gateway
Light
Light
Harbors,
Curve,
Land
Curve
Path
Canyon
Springs,
Suite
Apt.
Suite
Apt.
Apt.
Leblancland,
Suite
Lake
Suite
477,
North
044,
687,
274,
983,019,
Michael,
New
771,
Hunthaven,
Trujilloberg,
James,
Brennanland,
East
Lindaton,
Earltown,
Wallacebury,
Massachusetts
Steven,
New
Maryland
Iowa
Montana
Alaska
Mexico
Rhode
New 11. Age at the time
Tennessee
Illinois
Jersey
Island
of this birth:
Mother: Matthew
AdamLiBrown
Susan
Ryan
Amber
Nathan
Mary
Paul
Karen
Brittany
Hensley
Hernandez
Wright
Green
Huang
Peterson
Perry
Boone _______years
Father: Christopher
BruceKelly
Patrick
Marissa
James
Juan
John
Amy Hamilton
Wagner
Burns
Schmidt
English
Downs
LongButler
Pugh
62 64
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province)

13. NAME (First) (Middle) (Last)

68 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 79
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 81
_____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.
86 87
Signature ______________________________ Address ______________________________

Name in Print ___________________________ _____________________________________

Title or Position _________________________ Date _________________________________

_______________________________________________________________________________________________ 88 91

20. INFORMANT

Signature ______________________________ Address ______________________________

93
Name in Print ___________________________ _____________________________________

Relationship to the child ___________________ Date ________________________________

_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
94
Signature ______________________________ Signature _____________________________

Name in Print ___________________________ Name in Print __________________________

Title or Position _________________________ Title or Position ________________________

Date __________________________________ Date _________________________________
_______________________________________________________________________________________________
 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 _________________________________________ Registry No.

City/Municipality ___________________________________

1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:

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 (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) OFFICE OF THE CIVIL
H BIRTH House No., Street, Barangay) REGISTRAR
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 _____________
48

c. BIRTH ORDER (live births and fetal deaths d. WEIGHT AT BIRTH

including this delivery)
_____________ (first, second, third, etc.) ________________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME

7. CITIZENSHIP 8. RELIGION
56
M
O
T Name:9a.
Suzanne
Donald
Stephanie
Michelle
Richard
Janet
Sheri
John
Elijah
David Karen
Danielle
Shannon
Alison
Kyle
Total Lauren
Darryl
Elizabeth
Laura
Thomas
Paul
Mckee
numberMurphy Johnsonb.
Roberts
Collins
ofJohnson
Walker
Doyle
Martinez No. of Children still c. No. of children
Date of children
Birth: born
21-05-2024
24-03-2025
30-01-2024
14-05-2024
05-02-2025
25-07-2024
19-01-2024
21-03-2025
31-08-2024
17-03-2025 living including born alive but
H alive: _________ this birth: _________ are now dead: _________
E Sex: Male
Female 61
R Place 10. OCCUPATION
of Birth: 26496
1631
504
2017
26263
53586
9668
775
65026
288 Angela
Johnson
Diana
Latoya
James
Chelsea
Miller
Clark
Murillo
Claire
Gateway
Light
Light
Harbors,
Curve,
Land
Curve
Path
Canyon
Springs,
Suite
Apt.
Suite
Apt.
Apt.
Leblancland,
Suite
Lake
Suite
477,
North
044,
687,
274,
983,019,
Michael,
New
771,
Hunthaven,
Trujilloberg,
James,
Brennanland,
East
Lindaton,
Earltown,
Wallacebury,
Massachusetts
Steven,
New
Maryland
Iowa
Montana
Alaska
Mexico
Rhode
New 11. Age at the time
Tennessee
Illinois
Jersey
Island
of this birth:
Mother: Matthew
AdamLiBrown
Susan
Ryan
Amber
Nathan
Mary
Paul
Karen
Brittany
Hensley
Hernandez
Wright
Green
Huang
Peterson
Perry
Boone _______years
Father: Christopher
BruceKelly
Patrick
Marissa
James
Juan
John
Amy Hamilton
Wagner
Burns
Schmidt
English
Downs
LongButler
Pugh
62 64
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province)

13. NAME (First) (Middle) (Last)

68 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 79
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 81
_____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.
86 87
Signature ______________________________ Address ______________________________

Name in Print ___________________________ _____________________________________

Title or Position _________________________ Date _________________________________

_______________________________________________________________________________________________ 88 91

20. INFORMANT

Signature ______________________________ Address ______________________________

93
Name in Print ___________________________ _____________________________________

Relationship to the child ___________________ Date ________________________________

_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
94
Signature ______________________________ Signature _____________________________

Name in Print ___________________________ Name in Print __________________________

Title or Position _________________________ Title or Position ________________________

Date __________________________________ Date _________________________________
_______________________________________________________________________________________________
 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 _________________________________________ Registry No.

City/Municipality ___________________________________

1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:

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 (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) OFFICE OF THE CIVIL
H BIRTH House No., Street, Barangay) REGISTRAR
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 _____________
48

c. BIRTH ORDER (live births and fetal deaths d. WEIGHT AT BIRTH

including this delivery)
_____________ (first, second, third, etc.) ________________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME

7. CITIZENSHIP 8. RELIGION
56
M
O
T Name:9a.
Suzanne
Donald
Stephanie
Michelle
Richard
Janet
Sheri
John
Elijah
David Karen
Danielle
Shannon
Alison
Kyle
Total Lauren
Darryl
Elizabeth
Laura
Thomas
Paul
Mckee
numberMurphy Johnsonb.
Roberts
Collins
ofJohnson
Walker
Doyle
Martinez No. of Children still c. No. of children
Date of children
Birth: born
21-05-2024
24-03-2025
30-01-2024
14-05-2024
05-02-2025
25-07-2024
19-01-2024
21-03-2025
31-08-2024
17-03-2025 living including born alive but
H alive: _________ this birth: _________ are now dead: _________
E Sex: Male
Female 61
R Place 10. OCCUPATION
of Birth: 26496
1631
504
2017
26263
53586
9668
775
65026
288 Angela
Johnson
Diana
Latoya
James
Chelsea
Miller
Clark
Murillo
Claire
Gateway
Light
Light
Harbors,
Curve,
Land
Curve
Path
Canyon
Springs,
Suite
Apt.
Suite
Apt.
Apt.
Leblancland,
Suite
Lake
Suite
477,
North
044,
687,
274,
983,019,
Michael,
New
771,
Hunthaven,
Trujilloberg,
James,
Brennanland,
East
Lindaton,
Earltown,
Wallacebury,
Massachusetts
Steven,
New
Maryland
Iowa
Montana
Alaska
Mexico
Rhode
New 11. Age at the time
Tennessee
Illinois
Jersey
Island
of this birth:
Mother: Matthew
AdamLiBrown
Susan
Ryan
Amber
Nathan
Mary
Paul
Karen
Brittany
Hensley
Hernandez
Wright
Green
Huang
Peterson
Perry
Boone _______years
Father: Christopher
BruceKelly
Patrick
Marissa
James
Juan
John
Amy Hamilton
Wagner
Burns
Schmidt
English
Downs
LongButler
Pugh
62 64
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province)

13. NAME (First) (Middle) (Last)

68 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 79
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 81
_____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.
86 87
Signature ______________________________ Address ______________________________

Name in Print ___________________________ _____________________________________

Title or Position _________________________ Date _________________________________

_______________________________________________________________________________________________ 88 91

20. INFORMANT

Signature ______________________________ Address ______________________________

93
Name in Print ___________________________ _____________________________________

Relationship to the child ___________________ Date ________________________________

_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
94
Signature ______________________________ Signature _____________________________

Name in Print ___________________________ Name in Print __________________________

Title or Position _________________________ Title or Position ________________________

Date __________________________________ Date _________________________________
_______________________________________________________________________________________________
 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 _________________________________________ Registry No.

City/Municipality ___________________________________

1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:

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 (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) OFFICE OF THE CIVIL
H BIRTH House No., Street, Barangay) REGISTRAR
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 _____________
48

c. BIRTH ORDER (live births and fetal deaths d. WEIGHT AT BIRTH

including this delivery)
_____________ (first, second, third, etc.) ________________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME

7. CITIZENSHIP 8. RELIGION
56
M
O
T Name:9a.
Suzanne
Donald
Stephanie
Michelle
Richard
Janet
Sheri
John
Elijah
David Karen
Danielle
Shannon
Alison
Kyle
Total Lauren
Darryl
Elizabeth
Laura
Thomas
Paul
Mckee
numberMurphy Johnsonb.
Roberts
Collins
ofJohnson
Walker
Doyle
Martinez No. of Children still c. No. of children
Date of children
Birth: born
21-05-2024
24-03-2025
30-01-2024
14-05-2024
05-02-2025
25-07-2024
19-01-2024
21-03-2025
31-08-2024
17-03-2025 living including born alive but
H alive: _________ this birth: _________ are now dead: _________
E Sex: Male
Female 61
R Place 10. OCCUPATION
of Birth: 26496
1631
504
2017
26263
53586
9668
775
65026
288 Angela
Johnson
Diana
Latoya
James
Chelsea
Miller
Clark
Murillo
Claire
Gateway
Light
Light
Harbors,
Curve,
Land
Curve
Path
Canyon
Springs,
Suite
Apt.
Suite
Apt.
Apt.
Leblancland,
Suite
Lake
Suite
477,
North
044,
687,
274,
983,019,
Michael,
New
771,
Hunthaven,
Trujilloberg,
James,
Brennanland,
East
Lindaton,
Earltown,
Wallacebury,
Massachusetts
Steven,
New
Maryland
Iowa
Montana
Alaska
Mexico
Rhode
New 11. Age at the time
Tennessee
Illinois
Jersey
Island
of this birth:
Mother: Matthew
AdamLiBrown
Susan
Ryan
Amber
Nathan
Mary
Paul
Karen
Brittany
Hensley
Hernandez
Wright
Green
Huang
Peterson
Perry
Boone _______years
Father: Christopher
BruceKelly
Patrick
Marissa
James
Juan
John
Amy Hamilton
Wagner
Burns
Schmidt
English
Downs
LongButler
Pugh
62 64
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province)

13. NAME (First) (Middle) (Last)

68 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 79
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 81
_____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.
86 87
Signature ______________________________ Address ______________________________

Name in Print ___________________________ _____________________________________

Title or Position _________________________ Date _________________________________

_______________________________________________________________________________________________ 88 91

20. INFORMANT

Signature ______________________________ Address ______________________________

93
Name in Print ___________________________ _____________________________________

Relationship to the child ___________________ Date ________________________________

_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
94
Signature ______________________________ Signature _____________________________

Name in Print ___________________________ Name in Print __________________________

Title or Position _________________________ Title or Position ________________________

Date __________________________________ Date _________________________________
_______________________________________________________________________________________________
 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 _________________________________________ Registry No.

City/Municipality ___________________________________

1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:

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 (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) OFFICE OF THE CIVIL
H BIRTH House No., Street, Barangay) REGISTRAR
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 _____________
48

c. BIRTH ORDER (live births and fetal deaths d. WEIGHT AT BIRTH

including this delivery)
_____________ (first, second, third, etc.) ________________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME

7. CITIZENSHIP 8. RELIGION
56
M
O
T Name:9a.
Suzanne
Donald
Stephanie
Michelle
Richard
Janet
Sheri
John
Elijah
David Karen
Danielle
Shannon
Alison
Kyle
Total Lauren
Darryl
Elizabeth
Laura
Thomas
Paul
Mckee
numberMurphy Johnsonb.
Roberts
Collins
ofJohnson
Walker
Doyle
Martinez No. of Children still c. No. of children
Date of children
Birth: born
21-05-2024
24-03-2025
30-01-2024
14-05-2024
05-02-2025
25-07-2024
19-01-2024
21-03-2025
31-08-2024
17-03-2025 living including born alive but
H alive: _________ this birth: _________ are now dead: _________
E Sex: Male
Female 61
R Place 10. OCCUPATION
of Birth: 26496
1631
504
2017
26263
53586
9668
775
65026
288 Angela
Johnson
Diana
Latoya
James
Chelsea
Miller
Clark
Murillo
Claire
Gateway
Light
Light
Harbors,
Curve,
Land
Curve
Path
Canyon
Springs,
Suite
Apt.
Suite
Apt.
Apt.
Leblancland,
Suite
Lake
Suite
477,
North
044,
687,
274,
983,019,
Michael,
New
771,
Hunthaven,
Trujilloberg,
James,
Brennanland,
East
Lindaton,
Earltown,
Wallacebury,
Massachusetts
Steven,
New
Maryland
Iowa
Montana
Alaska
Mexico
Rhode
New 11. Age at the time
Tennessee
Illinois
Jersey
Island
of this birth:
Mother: Matthew
AdamLiBrown
Susan
Ryan
Amber
Nathan
Mary
Paul
Karen
Brittany
Hensley
Hernandez
Wright
Green
Huang
Peterson
Perry
Boone _______years
Father: Christopher
BruceKelly
Patrick
Marissa
James
Juan
John
Amy Hamilton
Wagner
Burns
Schmidt
English
Downs
LongButler
Pugh
62 64
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province)

13. NAME (First) (Middle) (Last)

68 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 79
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 81
_____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.
86 87
Signature ______________________________ Address ______________________________

Name in Print ___________________________ _____________________________________

Title or Position _________________________ Date _________________________________

_______________________________________________________________________________________________ 88 91

20. INFORMANT

Signature ______________________________ Address ______________________________

93
Name in Print ___________________________ _____________________________________

Relationship to the child ___________________ Date ________________________________

_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
94
Signature ______________________________ Signature _____________________________

Name in Print ___________________________ Name in Print __________________________

Title or Position _________________________ Title or Position ________________________

Date __________________________________ Date _________________________________
_______________________________________________________________________________________________
 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 _________________________________________ Registry No.

City/Municipality ___________________________________

1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:

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 (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) OFFICE OF THE CIVIL
H BIRTH House No., Street, Barangay) REGISTRAR
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 _____________
48

c. BIRTH ORDER (live births and fetal deaths d. WEIGHT AT BIRTH

including this delivery)
_____________ (first, second, third, etc.) ________________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME

7. CITIZENSHIP 8. RELIGION
56
M
O
T Name:9a.
Suzanne
Donald
Stephanie
Michelle
Richard
Janet
Sheri
John
Elijah
David Karen
Danielle
Shannon
Alison
Kyle
Total Lauren
Darryl
Elizabeth
Laura
Thomas
Paul
Mckee
numberMurphy Johnsonb.
Roberts
Collins
ofJohnson
Walker
Doyle
Martinez No. of Children still c. No. of children
Date of children
Birth: born
21-05-2024
24-03-2025
30-01-2024
14-05-2024
05-02-2025
25-07-2024
19-01-2024
21-03-2025
31-08-2024
17-03-2025 living including born alive but
H alive: _________ this birth: _________ are now dead: _________
E Sex: Male
Female 61
R Place 10. OCCUPATION
of Birth: 26496
1631
504
2017
26263
53586
9668
775
65026
288 Angela
Johnson
Diana
Latoya
James
Chelsea
Miller
Clark
Murillo
Claire
Gateway
Light
Light
Harbors,
Curve,
Land
Curve
Path
Canyon
Springs,
Suite
Apt.
Suite
Apt.
Apt.
Leblancland,
Suite
Lake
Suite
477,
North
044,
687,
274,
983,019,
Michael,
New
771,
Hunthaven,
Trujilloberg,
James,
Brennanland,
East
Lindaton,
Earltown,
Wallacebury,
Massachusetts
Steven,
New
Maryland
Iowa
Montana
Alaska
Mexico
Rhode
New 11. Age at the time
Tennessee
Illinois
Jersey
Island
of this birth:
Mother: Matthew
AdamLiBrown
Susan
Ryan
Amber
Nathan
Mary
Paul
Karen
Brittany
Hensley
Hernandez
Wright
Green
Huang
Peterson
Perry
Boone _______years
Father: Christopher
BruceKelly
Patrick
Marissa
James
Juan
John
Amy Hamilton
Wagner
Burns
Schmidt
English
Downs
LongButler
Pugh
62 64
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province)

13. NAME (First) (Middle) (Last)

68 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 79
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 81
_____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.
86 87
Signature ______________________________ Address ______________________________

Name in Print ___________________________ _____________________________________

Title or Position _________________________ Date _________________________________

_______________________________________________________________________________________________ 88 91

20. INFORMANT

Signature ______________________________ Address ______________________________

93
Name in Print ___________________________ _____________________________________

Relationship to the child ___________________ Date ________________________________

_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
94
Signature ______________________________ Signature _____________________________

Name in Print ___________________________ Name in Print __________________________

Title or Position _________________________ Title or Position ________________________

Date __________________________________ Date _________________________________
_______________________________________________________________________________________________
 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 _________________________________________ Registry No.

City/Municipality ___________________________________

1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:

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 (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) OFFICE OF THE CIVIL
H BIRTH House No., Street, Barangay) REGISTRAR
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 _____________
48

c. BIRTH ORDER (live births and fetal deaths d. WEIGHT AT BIRTH

including this delivery)
_____________ (first, second, third, etc.) ________________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME

7. CITIZENSHIP 8. RELIGION
56
M
O
T Name:9a.
Suzanne
Donald
Stephanie
Michelle
Richard
Janet
Sheri
John
Elijah
David Karen
Danielle
Shannon
Alison
Kyle
Total Lauren
Darryl
Elizabeth
Laura
Thomas
Paul
Mckee
numberMurphy Johnsonb.
Roberts
Collins
ofJohnson
Walker
Doyle
Martinez No. of Children still c. No. of children
Date of children
Birth: born
21-05-2024
24-03-2025
30-01-2024
14-05-2024
05-02-2025
25-07-2024
19-01-2024
21-03-2025
31-08-2024
17-03-2025 living including born alive but
H alive: _________ this birth: _________ are now dead: _________
E Sex: Male
Female 61
R Place 10. OCCUPATION
of Birth: 26496
1631
504
2017
26263
53586
9668
775
65026
288 Angela
Johnson
Diana
Latoya
James
Chelsea
Miller
Clark
Murillo
Claire
Gateway
Light
Light
Harbors,
Curve,
Land
Curve
Path
Canyon
Springs,
Suite
Apt.
Suite
Apt.
Apt.
Leblancland,
Suite
Lake
Suite
477,
North
044,
687,
274,
983,019,
Michael,
New
771,
Hunthaven,
Trujilloberg,
James,
Brennanland,
East
Lindaton,
Earltown,
Wallacebury,
Massachusetts
Steven,
New
Maryland
Iowa
Montana
Alaska
Mexico
Rhode
New 11. Age at the time
Tennessee
Illinois
Jersey
Island
of this birth:
Mother: Matthew
AdamLiBrown
Susan
Ryan
Amber
Nathan
Mary
Paul
Karen
Brittany
Hensley
Hernandez
Wright
Green
Huang
Peterson
Perry
Boone _______years
Father: Christopher
BruceKelly
Patrick
Marissa
James
Juan
John
Amy Hamilton
Wagner
Burns
Schmidt
English
Downs
LongButler
Pugh
62 64
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province)

13. NAME (First) (Middle) (Last)

68 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 79
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 81
_____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.
86 87
Signature ______________________________ Address ______________________________

Name in Print ___________________________ _____________________________________

Title or Position _________________________ Date _________________________________

_______________________________________________________________________________________________ 88 91

20. INFORMANT

Signature ______________________________ Address ______________________________

93
Name in Print ___________________________ _____________________________________

Relationship to the child ___________________ Date ________________________________

_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
94
Signature ______________________________ Signature _____________________________

Name in Print ___________________________ Name in Print __________________________

Title or Position _________________________ Title or Position ________________________

Date __________________________________ Date _________________________________
_______________________________________________________________________________________________
 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 _________________________________________ Registry No.

City/Municipality ___________________________________

1. NAME (First) (Middle) (Last) FOR OCRG USE ONLY:

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 (Name of Hospital/Clinic/Institution/ (City/Municipality) (Province) OFFICE OF THE CIVIL
H BIRTH House No., Street, Barangay) REGISTRAR
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 _____________
48

c. BIRTH ORDER (live births and fetal deaths d. WEIGHT AT BIRTH

including this delivery)
_____________ (first, second, third, etc.) ________________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME

7. CITIZENSHIP 8. RELIGION
56
M
O
T Name:9a.
Suzanne
Donald
Stephanie
Michelle
Richard
Janet
Sheri
John
Elijah
David Karen
Danielle
Shannon
Alison
Kyle
Total Lauren
Darryl
Elizabeth
Laura
Thomas
Paul
Mckee
numberMurphy Johnsonb.
Roberts
Collins
ofJohnson
Walker
Doyle
Martinez No. of Children still c. No. of children
Date of children
Birth: born
21-05-2024
24-03-2025
30-01-2024
14-05-2024
05-02-2025
25-07-2024
19-01-2024
21-03-2025
31-08-2024
17-03-2025 living including born alive but
H alive: _________ this birth: _________ are now dead: _________
E Sex: Male
Female 61
R Place 10. OCCUPATION
of Birth: 26496
1631
504
2017
26263
53586
9668
775
65026
288 Angela
Johnson
Diana
Latoya
James
Chelsea
Miller
Clark
Murillo
Claire
Gateway
Light
Light
Harbors,
Curve,
Land
Curve
Path
Canyon
Springs,
Suite
Apt.
Suite
Apt.
Apt.
Leblancland,
Suite
Lake
Suite
477,
North
044,
687,
274,
983,019,
Michael,
New
771,
Hunthaven,
Trujilloberg,
James,
Brennanland,
East
Lindaton,
Earltown,
Wallacebury,
Massachusetts
Steven,
New
Maryland
Iowa
Montana
Alaska
Mexico
Rhode
New 11. Age at the time
Tennessee
Illinois
Jersey
Island
of this birth:
Mother: Matthew
AdamLiBrown
Susan
Ryan
Amber
Nathan
Mary
Paul
Karen
Brittany
Hensley
Hernandez
Wright
Green
Huang
Peterson
Perry
Boone _______years
Father: Christopher
BruceKelly
Patrick
Marissa
James
Juan
John
Amy Hamilton
Wagner
Burns
Schmidt
English
Downs
LongButler
Pugh
62 64
12. RESIDENCE (House No., Street, Barangay) (City/Municipality) (Province)

13. NAME (First) (Middle) (Last)

68 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 79
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 81
_____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.
86 87
Signature ______________________________ Address ______________________________

Name in Print ___________________________ _____________________________________

Title or Position _________________________ Date _________________________________

_______________________________________________________________________________________________ 88 91

20. INFORMANT

Signature ______________________________ Address ______________________________

93
Name in Print ___________________________ _____________________________________

Relationship to the child ___________________ Date ________________________________

_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
94
Signature ______________________________ Signature _____________________________

Name in Print ___________________________ Name in Print __________________________

Title or Position _________________________ Title or Position ________________________

Date __________________________________ Date _________________________________
_______________________________________________________________________________________________