Municipal Form No. 102 {To be accomplished in quacropcate using black hk (Revised January 2007) Republic of the Philippines : om OFFICE OF THE CIVIL REGISTRAR GENERAL CERTIFICATE OF LIVE BIRTH aa Registry No. rovincs__ joo = cer City/Municipality POTOTAN har a 20}7- 2474 7 NAME Fist Tcaey Tay 4 LUKE CARPIO | sXe Fenae) i DATEOF (omy) (Month) ear) H 2 44 __ NOVEMBER 2017 (PLAC me ns Cinna vs} Terre Fis RSE Barangay) a aa : Lo N i eee DS TYPEOFBIRTH 52 IFMULTIPLEBIRTH,CHLDWAS 56 BIRTHORDER csrsnov » (6 WEIGHTATBIRTH (Grave) (Pr Secon, Ted) peootiessreyermaey SINGLE. = NOT APPLICABLE SECOND 3400___ grams 7 MAE rs) (Mil) rr) M|_““* MARY MICHELLE JMOL. CARPIO | | Someensa 9. RELIGIONRELIGOUSSECT T | FILIPINO |_ROMAN CATHOLIC H 0a Tatruner of 76; of oan wn |e asain tom |1.OCCUPATIN 12 AGE ae eo | gems rete E ics pare ee R aa: RESCENCE (owe No, St, Barney) (GniManeipaliy) _Provnesy (oan) BARANGAY IWA ILAYA POTOTAN ILOILO PHILIPPINES pe Mwe Fis ‘iy ta R NOT APPLICABLE, ___ NOT APPLICABLE NOT APPLICABLE 7 Sommewr RRLGIOWRELGOUSSEET YOcuRATEN 8. Armee compa es HH NOT APPLICABLE NOT APPLICABLE NOT APPLICABLE E |e RESDENCE ist. SL ay ‘Giontoriceaiyn Prowes) (Cour) |" |_NOT APPLICABLE NOT APPLICABLE —— TANILOILO- Date MARRIAGE OF PARENTS i rot mares, accomplish Aa of AcknowacpemantAdnission of Pateriy a te back) a DATE (Month) (Day) (Year) 200.PLACE (Cly/ Muriciplty) (Province (Country) Tite or Postion MEDICAL OFFICER Il —__Dale_ NOVEMBER 18, 2017 23 PREPARED BY Signatur Name in Print ALPINE A. PORRAS Retatorshipiohe Ch_MOTHER Teor Postion ADMINISTRATIVE _OFFICER | mt REMARREIANNOTAT ONG Roch rorocRG Use Gals)Republic of the Philippines Social Security System “ Medical Benefits Section wame:_Madot havthulle Galas Sss#:__ COMPLETE OBSTETRICAL HISTORY (To be filed up by attending OB-Gynecotogis) Gat, (20a) DETAILED OB HISTORY (Complete data below using this format) OBSTETRICAL SCORE: or=___ Cekauariplo ff 1° wis Date G2e ov 14, 20 fugeat me “TST, Date 19 . Type of Delivery G3 a. ye Daivany Gas Type of Delivery Type of Delivery ‘OTHER REMARKS (If any): This serves as the member's Medical Certificate. Or. ma, Winid) L. oon Print Name and Signature ATTENDING OB8-GYNE/Midwife License #:__00 $47 & Buti ‘F Appiicatiey