DRAFT NEW CERTIFICATE OF LIVE BIRTH
Province
City/Municipality DAVAO CITY
Name (First) (Middle)
(La
MAXINE SOLLETTE BAJA VALENZON
x (Male/Female) Date of Birth (Day) (Month) (Year)
FEMALE 10 SEPTEMBER 2021
CHILD
e of Birth (Name of Hospital/Clinic/Institution/ City/Municipality
SOUTHERN PHILIPPINES MEDICAL CENTER DAVAO CITY
Type of Birth (Single,Twin,Triplet, If Multiple Birth, Child was Birth Order (first, second, third, etc.)
etc.) SINGLE (First,Second,Third, etc.) N/A FIRST
Maiden Name (First) (Middle) (Last)
ELMA MARIMON BAJA
Citizenship FILIPINO Religion/Religiuous Sect ROMA
Mother
Total Number of No. of Children No. of Children Born Alive But Occupation
Children Born Alive Living Including are now dead TEACHER
1 This Birth 1 0
Residence (House No. St. Brgy) (City/Municipality)
PUROK 5-A BARANGAY PENAPLATA, ISLAND GARDEN CITY OF SAMAL, DA
Name (First) (Middle) (Last)
ALREX JUNA SILAWAN
Citizenship FILIPINO Religion/Religiuous Sect ROMA
Father
Occupation: TEACHER Age at the time of this birth 3
Residence (House No. St. Brgy) (City/Municipality)
PUROK 5-A BARANGAY PENAPLATA, ISLAND GARDEN CITY OF SAMAL, DA
Marriage of Parents (If not married, accomplish Affidavit of Acknowledgement of Paternity at the back)
Date (Month) (Day) (Year) Place (City/Muncipality) (Province)
29 MARCH 2011 ISLAND GARDEN CITY OF SAMAL DAVAO DEL NORTE
P
Attendant
Physician Nurse Midwife Hilot (Traditional Birth Attendant) Other
Certification of Attendant at birth
I hereby certify that I attended the birth of the child who was born alive at 12:10 am/pm on the date of birth specif
Signature SGD. Address: SOUTHERN PHILIPPINES MED
Name in Print: CLARISSA LEA R. LUCAS, MD BAJADA, DAVAO CITY
Title or Position: PHYSICIAN Date: _SEPTEMBER 13, 2021
Certificate of Informant Prepared by
I hereby certify that all information supplied are true and
correct to my own knowledge and belief.
Signature Signature SGD.
Name in Print ALREX J. SILAWAN Name in Print JEMARI G. VILLALUZ
Relationship to the Child Father Title or Position_ADMINISTRATIVE OFFIC
Address PUROK 5-A BARANGAY PENAPLATA, ISLANG
GARDEN CITY OF SAMAL, DAVAO DEL NORTE Date _SEPTEMBER 13, 2021
st)
Province
Weight at birth
2890 grams
N CATHOLIC
Age at the time of this
birth (completed years) 36
(Province)
VAO DEL NORTE
N CATHOLIC
5
(Province)
VAO DEL NORTE
(Country)
HILIPPINES
s pls specify
ied above.
ICAL CENTER ,
ER III
Date _SEPTEMBER 13, 2021
Received by Registered At The Office of the Civil Regi
Signature SGD. Signature SGD.
Name in Print_ARLENE C. VIERNES Name in Print_ADELINA C. PERIQIET
Title or Position ADMIN AIDE IV Title or Position ACTING HEAD-DEATH
Date _OCTOBER 1, 2021 Date _OCTOBER 1, 2021
Prepared by: Verified by:
JACQUILINE I. BADUA ALREX J. SILAWAN & ELMA B. SILAWAN
Social Welfare Officer II Prospective Adoptive Parents
strar
& LICD DIV
AFFIDAVIT OF ACKNOWLEDGMENT/ADMISSION OF PATERNITY
(For births before 3 August 1988) (For births on or after 3 August 1988)
I/We, and
age, am/are the natural mother and/or father of , who wa
on at .
I am/We are executing this affidavit to attest to the truthfulness of the foregoin statements a
purposes of acknowledging my/our child.
Signature Over Printed Name of Father Signature Over Printed Name of Mother
SUBSCRIBED AND SWORN to before me this day of ,
by ,
and , who exhibited to me (his/her) any government issued
ID issued on at
Signature of the Administering Officer Position / Title /Designation
Name in Print Address
AFFIDAVIT OF DELAYED REGISTRATION OF BIRTH
(To be accomplished by the hospital/clinic administrator, father, mother, or guardian or the person himself if 18 years old or
over)
, of legal
s born
nd for
I, , of legal age, single/married/widowed/divorced, with re
and postal address at , after having been duly sworn in accordance with
hereby depose and say:
1. That I am the applicant for the delayed registration of:
my birth in
on .
the birth of who was born in
on .
2. That I/he/she was attended at birth by
who
resides at
.
3. That I am/he/she is a citizen of
4. That y/his.her parents were married on
at
not married but I/he/she was acknowledged/not acknowl
my/his/her father whose name is
5. That the reason for the delay in registering my/his/her birth was
.
6. (For the applicant only) That I am married to
(if the applicant is other than the document owner) That I am the
the
said person.
7. That I am eecuting this affidavit to attest to the truthfulness of the foregoing statements for
intents
and purposes.
(Signature Over Printed Name of Aff
SUBSCRIBED AND SWORN to before me this day of ,
by ,
and , who exhibited to me (his/her) any government issued
ID issued on at
Signature of the Administering Officer Position / Title /Designation
Name in Print Address
sidence
law, do
_.
e dged by
.
of
a ll legal
iant)
