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.)
CAVITE Registry No.
Province
City/Municipality MAGALLANES 2025-4809
1. NAME (First) (Middle) (Last) For OCRG USE ONLY.
Pupolation Reference No.
ROCHELLE GLORIANI RAMOS
2. SEX 3. DATE OF BIRTH (Day) (Month) (Year)
X
____ 1 Male ______ 2 Female 16 MAY 1978 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
MAGALLANES CAVITE 9 0 7 6 8 9 6
b. IF MULTIPLE BIRTH CHILD WAS
D 5a. TYPE OF BIRTH
X
____ 1 Single ______ 2 Twin ____ 1 First ______ 2 Second
______ 3 Triplets, etc. ______ 3 Others, Specity __________
48
C. BIRTH ORDER (Order of this birt to
previous live birth including fetal death
4
SIXTH (First, Second, Third, etc.) 3,000
___________ grams
49 50
6. MAIDEN (First) (Middle) (Last)
NAME
5 6 7 4 5 5 6
FRANCISKA PANGANIBAN GLORIANI
7. CITIZENSHIP 8 . RELIGION
M FILIPINO ROMAN CATHOLIC 51
O 9a. Total number of b. No. of children still c. No. of children 0 9 6 6 5
T children born
6
alive ______________
living including
6
born alive but
0
are now dead ___________
this birth _____________
H
E 10. OCCUPATION 11. Age at the time of this 61
R birth (completed year) 4
HOUSEWIFE 35
____________years
12. RESIDENCE (House No. St. Barangay) (City/Municipality) (Province) 62 64
MAGALLANES CAVITE 8 8 6 7 8 7
F 13. NAME
(First) (Middle) (Last)
A ROGELIO TAPIA RAMOS 68 69
T 14. CITIZENSHIP 15 . RELIGION
ROMAN CATHOLIC
0 9 1
H FILIPINO
E 16. OCCUPATION 17. Age at the time of this
R birth (completed year) 70 72 74
FISHERMAN 37
____________years
18. DATE AND PLACE OF MARRIAGE OF PARENTS (If not married, accomplish Affidavit of
5 5 6 6 7 6
acknowledge/ Admission of Paternity at the back.)
N/A
19a. ATTENDANT 76 79
X 1 Physician
______ _______2 Nurse _______3 Midwife 5 6 7 6 7
_______Hilot (Tranditinal Birth Attendant) _______ 5 Others (Specify)
19b. CERTIFICATION OF BIRTH
1:08
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. 6 6 6 8 0
AddressMAGALLANES
Signature _____________________________________ CAVITE
____________________________________
CINDYVY RUPITA M.D. __________________________________________
Name in Print __________________________________
86 87
17 MAY 1978
MEDICAL SPECIALIST IIDate ______________________________________
Title or Position _________________________________
20. IMFORMANT
6 6
Signature _____________________________________
MAGALLANES CAVITE
Address ____________________________________ 88 91
FRANCISCA P. GLORIANI
Name in Print __________________________________ __________________________________________
6 8 9 0 8
MOTHER
Relationship to the Child ________________________ 17 MAY 1978
Date ______________________________________
21. PREPARED BY 22. REGISTERED AT THE OFFICE OF
THE CIVIL REGISTRAR 93
Signature _____________________________________ Signature _________________________________
7
ANALEE D. FLORETA
Name in Print _________________________________ CORA A. ENARGAN
Name in Print______________________________
CCRD CLERK
Title or Position _______________________________ CITY CIVIL REGISTRAR94
Titke in Position___________________________
MAY 20, 2025
Date __________________________________________ MAY 20, 2025
Date ______________________________________
0
06481-H6-005FSA-00236-B|002 BReN
BEST POSSIBLE IMAGE 05806-B00G201-3 CLAIRE DENNIS S. MAPA, Ph. D.
National Statistician and Civil Registrar
General
Documentary
T0050848100500236092920017002
Philippine Statistics Authority
NL7D00589445
Stamp Tax Paid
