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Blank Birth Certificate Form
Blank Birth Certificate Form
Municipal Form No. 102 (To be accomplished in quadruplicate)
(Revised January 1993)
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 ___________________________________
REMARKS/ANNOTATION
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
_____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.
Signature ______________________________ Address ______________________________
Name in Print ___________________________ _____________________________________
Title or Position _________________________ Date _________________________________
_______________________________________________________________________________________________
20. INFORMANT
Signature ______________________________ Address ______________________________
Name
in Print ___________________________ _____________________________________
Relationship to the child ___________________ Date ________________________________
_______________________________________________________________________________________________
21. PREPARED BY 22. RECEIVED AT THE OFFICE OF
THE CIVIL REGISTRAR
Signature ______________________________ Signature _____________________________
Name in Print ___________________________ Name in Print __________________________
Title or Position _________________________ Title or Position ________________________
Date __________________________________ Date _________________________________
_______________________________________________________________________________________________
FOR OCRG USE ONLY
:
Population reference No.
TO BE FILLED UP AT THE
OFFICE OF THE CIVIL
REGISTRAR
41
48
49 50
56
61
62 64
68 69
70 72 74
76 79
81
86 87
88 91
93
94
1. NAME (First) (Middle) (Last)
2. SEX 3. DATE OF BIRTH
(day) (month) (year)
______ 1 Male _______ 2 Female
4. PLACE OF
(Name of Hospital/Clinic/Institution/ (City/Municipality) (Province)
BIRTH
House No., Street, Barangay)
5a. TYPE OF BIRTH b. IF MULTIPLE BIRTH, CHILD WAS
_____ 1 Single ______ 2 Twin _____ 1 First ______ 2 Second
______ 3 Triplet. Etc. ______ 3 Others, Specify _____________
c. BIRTH ORDER
(live births and fetal deaths
d. WEIGHT AT BIRTH
including this delivery)
_____________ (first, second, third, etc.) ________________ grams
6. MAIDEN (First) (Middle) (Last)
NAME
7. CITIZENSHIP 8. RELIGION
9a.
Total number of
b.
No. of Children still
c. No. of children
children born living including born alive but
alive: _________ this birth: _________ are now dead: _________
10. OCCUPATION 11.
Age at the time
of this birth:
_______years
12. RESIDENCE
(House No., Street, Barangay) (City/Municipality) (Province)
13. NAME (First) (Middle) (Last)
14. CITIZENSHIP 15. RELIGION
16. OCCUPATION 17.
Age at the time
of this birth:
_______years
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